Elizabeth Ainsworth, MOccThy, Grad Cert Health Sci
Private Practice Occupational Therapist and Access Consultant
Home Design for Living
Coorparoo, Australia
Desleigh de Jonge, MPhil (OccThy), Grad Cert Soc Sci
Adjunct Research Fellow
School of Health and Rehabilitation Sciences
The University of Queensland
St Lucia, Australia
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An Occupational Therapist’s Guide to Home Modification Practice, Second Edition includes ancillary materials specifically available for faculty use. Please visit http://www.efacultylounge.com to obtain access.
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Library of Congress Cataloging-in-Publication Data
Names: Ainsworth, Elizabeth, author. | De Jonge, Desleigh, author.
Title: An occupational therapist’s guide to home modification practice /
Elizabeth Ainsworth, MOccThy, Grad Cert Health Sci, Private Practice
Occupational Therapist and Access Consultant, Home Design for Living,
Coorparoo, Australia, Desleigh de Jonge, MPhil (OccThy), Grad Cert Soc
Sci, Adjunct Research Fellow, School of Health and Rehabilitation
Sciences, The University of Queensland, St Lucia, Australia.
Description: Second edition. | Thorofare : Slack Incorporated, [2018] |
Includes bibliographical references and index.
Identifiers: LCCN 2018037252 (ebook) | ISBN
9781630912192 (epub) | ISBN 9781630912208 (web)
Subjects: LCSH: Occupational therapy. | Home care services. | People with
disabilities--Housing--Design and construction. | BISAC: MEDICAL / Allied
Health Services / Occupational Therapy.
Classification: LCC RM735 (ebook) | LCC RM735 .A635 2018 (print) | DDC
615.8/515--dc23
LC record available at https://lccn.loc.gov/2018035903
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DEDICATION
Dedicated to our families and friends, who have loved and supported us during this project, and to our
clients, who provide inspiration and wisdom to expand our thinking and our practice and who challenge
us to make a real difference in their lives. We would also like to dedicate this book to our colleagues who
continue to embrace the complexities within the home environment to achieve quality outcomes for older
people and people with disabilities.
CONTENTS
Dedication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ix
About the Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xi
Contributing Authors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xiii
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
Foreword by Carolyn Baum, PhD, OTR/L, FAOTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii
Chapter 1
The Home Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
Tammy Aplin, PhD, BOccThy (Hons) and
Bronwyn Tanner, BOccThy, Grad Cert Occ Thy, Grad Cert Soc Planning, MPhil
Chapter 2
Approaches to Service Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Bronwyn Tanner, BOccThy, Grad Cert Occ Thy, Grad Cert Soc Planning, MPhil;
Desleigh de Jonge, MPhil (OccThy), Grad Cert Soc Sci; Andrew Jones, BA, MSW, GCE;
Rhonda Phillips, MPhil, BA, Grad Dip; and Jon Pynoos, MCP, PhD
Chapter 3
Models of Occupational Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Desleigh de Jonge, MPhil (OccThy), Grad Cert Soc Sci
and Merrill Turpin, PhD, Grad Dip Counsel, BOccThy
Chapter 4
Legislation, Regulations, Codes, and Standards Influencing
Home Modification Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63
Elizabeth Ainsworth, MOccThy, Grad Cert Health Sci;
Desleigh de Jonge, MPhil (OccThy), Grad Cert Soc Sci; and Jon Sanford, MArch, BS
Chapter 5
The Home Modification Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .83
Elizabeth Ainsworth, MOccThy, Grad Cert Health Sci
and Desleigh de Jonge, MPhil (OccThy), Grad Cert Soc Sci
Chapter 6
Evaluating Clients’ Home Modification Needs and Priorities. . . . . . . . . . . . . . . . . . . . . . . . . . 111
Desleigh de Jonge, MPhil (OccThy), Grad Cert Soc Sci
and Melanie Hoyle, BSc (Psych), MOccThySt, Grad Dip Health Sci, Post Grad Dip Psych
Chapter 7
Measuring the Person and the Home Environment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Elizabeth Ainsworth, MOccThy, Grad Cert Health Sci
and Desleigh de Jonge, MPhil (OccThy), Grad Cert Soc Sci
Chapter 8
Drawing the Built Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Elizabeth Ainsworth, MOccThy, Grad Cert Health Sci
and Desleigh de Jonge, MPhil (OccThy), Grad Cert Soc Sci
Chapter 9
Developing and Tailoring Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .195
Desleigh de Jonge, MPhil (OccThy), Grad Cert Soc Sci;
Melanie Hoyle, BSc (Psych), MOccThySt, Grad Dip Health Sci, Post Grad Dip Psych;
and Elizabeth Ainsworth, MOccThy, Grad Cert Health Sci
Chapter 10
Sourcing and Evaluating Products and Designs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .225
Desleigh de Jonge, MPhil (OccThy), Grad Cert Soc Sci
and Melanie Hoyle, BSc (Psych), MOccThySt, Grad Dip Health Sci, Post Grad Dip Psych
Chapter 11
Access Standards and Their Role in Guiding Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
Elizabeth Ainsworth, MOccThy, Grad Cert Health Sci;
Desleigh de Jonge, MPhil (OccThy), Grad Cert Soc Sci;
and Bronwyn Tanner, BOccThy, Grad Cert Occ Thy, Grad Cert Soc Planning, MPhil
viii
Contents
Chapter 12
Ethical, Legal, and Reporting Variables: Pathways to Best Practice. . . . . . . . . . . . . . . . . . . .259
Elizabeth Ainsworth, MOccThy, Grad Cert Health Sci
and Barbara Kornblau, JD, OTR/L, FAOTA, FNAP, DASPE, CDMS, CCM, CPE
Chapter 13
Evaluating Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .283
Desleigh de Jonge, MPhil (OccThy), Grad Cert Soc Sci
and Melanie Hoyle, BSc (Psych), MOccThySt, Grad Dip Health Sci, Post Grad Dip Psych
Chapter 14
Literature Review: Home Modification Outcomes for Older Adults and
Adults With Disabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
Elizabeth Ainsworth, MOccThy, Grad Cert Health Sci; Tammy Aplin, PhD, BOccThy (Hons);
Louise Gustafsson, PhD, BOccThy (Hons); and Desleigh de Jonge, MPhil (OccThy), Grad Cert Soc Sci
Chapter 15
Case Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .337
Elizabeth Ainsworth, MOccThy, Grad Cert Health Sci; Kathleen Baigent, Dip COT, Dip Health Prom;
Ruth Cordiner, Dip COT, Grad Cert Occ Thy; Shirley Darlison, BOccThy; and May Eade, BOccThy
Appendix
Appendix
Appendix
Appendix
Appendix
Appendix
Appendix
Appendix
Appendix
A
B
C
D
E
F
G
H
I
Minor Modifications: It’s Not as Simple as “Do It Yourself” (DIY). . . . . . . . . . . . . . . . . . . . . .
Outline of Shapes and Occupied Wheelchairs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Fundamental Types of Compact Turns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Ramp Installation Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Home Modification Practice Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Access Standards Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Home Visit Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Home Modification Report Template . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Example of an Occupational Therapy Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
381
389
391
395
415
419
421
433
443
Financial Disclosures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 455
An Occupational Therapist’s Guide to Home Modification Practice, Second Edition includes ancillary materials specifically available for faculty use. Please visit http://www.efacultylounge.com to obtain access.
ACKNOWLEDGMENTS
We would like to thank Brien Cummings and staff at SLACK Incorporated for providing us with the opportunity to showcase occupational therapy research and practice, and for supporting and promoting our work.
We are grateful for the generous support and assistance of the various knowledgeable writers and others
who contributed to the first edition of the book, and to those who reviewed and contributed new material
for this second edition.
We thank our clients and colleagues around the world who have read and used the first edition, and provided us with invaluable feedback to further refine the book.
We are indebted to our colleagues at The University of Queensland who have provided us with encouragement and support to continue refining the material gathered from our home modification research and
practice.
Finally, we would like to thank our partners and families for providing us with support and encouragement as we have worked on this project for our profession and for older people and people with disabilities
over the last decade.
ABOUT
THE
AUTHORS
Elizabeth Ainsworth, MOccThy, Grad Cert Health Sci graduated in 1989 with a bachelor of occupational
therapy (honors) degree and completed a master’s in occupational therapy (contemporary clinical practice
at the University of Queensland) and a graduate certificate in health science (environmental modifications at
the University of Sydney) in 2000. She is a private practice occupational therapist, accredited and qualified
access consultant, and PhD candidate at The University of Queensland.
Elizabeth has had over 20 years’ experience aiding older people and people with disabilities who require
home modifications or alternative housing. She has a history of working in government and non-government
agencies that assist people living in a range of housing tenures such as private and social housing and private rental accommodation. Elizabeth provides consultancy services to clients and their families, and to
organizations, about housing and home modification solutions. She also completes medico legal work, providing information to the courts in Australia and overseas about the housing and home modification needs
of people who have had complex or catastrophic injuries. She provides home modification and universal
design education and training to occupational therapy university undergraduate and postgraduate students
and to occupational therapy clinicians working in a range of settings in the community, both in Australia
and overseas. She is a member of the Australian Network for Universal Housing Design (ANUHD), Universal
Design Australia, the Australian Access Consultants Association (ACAA), the Australian Rehabilitation and
Assistive Technology Association (ARATA), and Values in Action.
Desleigh de Jonge, MPhil (OccThy), Grad Cert Soc Sci graduated in 1978 with a bachelor of occupational
therapy from The University of Queensland, completed a master’s in philosophy in 2001, and is currently
completing a PhD at this university. She has over 35 years’ clinical experience as an occupational therapist
and 12 years teaching and research at the School of Health and Rehabilitation Sciences at The University
of Queensland, where she currently holds an honorary research title. Her teaching and research is focused
on interventions and outcome measures that recognize client goals and priorities. Desleigh’s national and
international reputation in client-oriented analysis of assistive technologies, environmental design, and
home modifications has earned her invitations to present at international conferences on assistive technology and home modification services and outcomes in the United States and Australia, and she has been
published extensively in national and international journals. Desleigh was on the editorial board of Disability
and Rehabilitation: Assistive Technology from 2006 to 2012 and regularly reviews articles for national and
international journals.
Elizabeth and Desleigh have worked together for at least 18 years to provide training to occupational
therapy students and practitioners. They have presented at national and international conferences on home
modifications and universal design to a broad range of people from various backgrounds. The second edition of this book is testament to their dedication to equipping occupational therapists to achieve quality
home modification outcomes for older people and people with disabilities internationally.
CONTRIBUTING AUTHORS
Tammy Aplin, PhD, BOccThy (Hons) (Chapters 1, 14)
Lecturer
Division of Occupational Therapy
School of Health and Rehabilitation Sciences
The University of Queensland
St Lucia, Brisbane, Queensland, Australia
Kathleen Baigent, Dip COT, Dip Health Prom
(Chapter 15)
Occupational Therapist
Housing and Homelessness Services
Queensland Department of Housing and Public
Works
Brisbane, Queensland, Australia
Ruth Cordiner, Dip COT, Grad Cert Occ Thy
(Chapter 15)
Occupational Therapist
Housing and Homelessness Services
Queensland Department of Communities
Brisbane, Queensland, Australia
Shirley Darlison, BOccThy (Chapter 15)
Senior Occupational Therapist
Housing and Homelessness Services
Queensland Department of Housing and Public
Works
Brisbane, Queensland, Australia
May Eade, BOccThy (Chapter 15)
Former Senior Occupational Therapist
Queensland Department of Housing and Public
Works
Brisbane, Queensland, Australia
Louise Gustafsson, PhD, BOccThy (Hons) (Chapter 14)
Associate Professor
Division of Occupational Therapy
School of Health and Rehabilitation Sciences
The University of Queensland
St Lucia, Brisbane, Queensland, Australia
Melanie Hoyle, BSc (Psych), MOccThySt, Grad Dip
Health Sci, Post Grad Dip Psych (Chapters 6, 9,
10, 13)
Honorary Associate Lecturer/PhD Candidate
School of Health and Rehabilitation Sciences
The University of Queensland
St Lucia, Brisbane, Queensland, Australia
Andrew Jones, BA, MSW, GCE (Chapter 2)
Emeritus Professor
The University of Queensland
St Lucia, Brisbane, Queensland, Australia
Barbara Kornblau, JD, OTR/L, FAOTA, FNAP, DASPE,
CDMS, CCM, CPE (Chapter 12)
Adjunct Professor
Florida Agricultural and Mechanical University
Tallahassee, Florida
Rhonda Phillips, MPhil, BA, Grad Dip (Chapter 2)
Adjunct Research Fellow
Institute of Social Science Research
The University of Queensland
St Lucia, Brisbane, Queensland, Australia
Jon Pynoos, MCP, PhD (Chapter 2)
UPS Foundation Professor of Gerontology, Policy
and Planning
Andrus Gerontology Center
Director, National Resource Center on Supportive
Housing and Home Modification
Co-Director, Fall Prevention Center of Excellence
University of Southern California
Los Angeles, California
Jon Sanford, MArch, BS (Chapter 4)
Professor, School of Industrial Design
Director, Center for Assistive Technology and
Environmental Access (CATEA)
Georgia Institute of Technology
Atlanta, Georgia
Bronwyn Tanner, BOccThy, Grad Cert Occ Thy, Grad
Cert Soc Planning, MPhil (Chapters 1, 2, 11)
College of Healthcare Sciences
James Cook University
Queensland, Australia
Merrill Turpin, PhD, Grad Dip Counsel, BOccThy
(Chapter 3)
Senior Lecturer, Occupational Therapy
School of Health and Rehabilitation Sciences
The University of Queensland
St Lucia, Brisbane, Queensland, Australia
xiv
Contributing Authors
General Contributors to the Book
Catherine Bridge, PhD, Arch, BAppSc, MCogSci
Director, Home Modification Information Clearinghouse
Research Leader, Community Engagement CRC LCL—
Faculty Leadership
Associate Dean of Research, ADR Unit
Architectural Studies
Architecture, Enabling Environments Program
Smart Cities
University of New South Wales
Sydney, Australia
Diane Bright, OTR, MSc ID
Director, Alliance Therapy/Access Answers
Troy, Michigan
Ben Burton, PG Dip Surv, LLB
idapt planner 3D (part of the idapt Group)
Bristol, England
Nigel Burton, CIOB, MAPM, MAPS, MCMI
idapt planner 3D (part of the idapt Group)
Bristol, England
Paul Coonan, BDesSt, BArch
Registered Architect (Queensland)
Director, Queensland Government Accommodation Office
Queensland Department of Housing and Public Works
Brisbane, Queensland, Australia
Richard Duncan, BA, MRP
Executive Director, Universal Design Institute
Better Living Design Institute
Asheville, North Carolina
Alan Healey, BOccThy
Occupational Therapist, Housing and Homelessness
Services
Queensland Department of Housing and Public Works
Brisbane, Queensland, Australia
Mitch Hubbard, BOccThy
Director, OT Draw
Sales and Support
Insighted Pty Ltd
New South Wales, Australia
Rodney Hunter, FDip, Arch RMIT, Architect (Retired)
Managing Director, Rod A Hunter and Associates Pty
Ltd
T/A Hunarch Consulting
Balwyn, Victoria, Australia
Rob Imrie
Visiting Professor
Goldsmiths, University of London
London, England
Richard Kirk, BDesSt, BArch
Registered Architect (Qld)
Director, Richard Kirk Architect
Brisbane, Queensland, Australia
Kate Kirkness BOccThy
Occupational Therapist
Scope Home Access
New England Region, New South Wales, Australia
Trish Lapsley, BOccThy
Private Practice Occupational Therapist
Brisbane, Queensland, Australia
Mary Law, PhD, FCAOT, FCAHS
Professor Emeritus, School of Rehabilitation Science
Co-Founder, CanChild Centre for Childhood Disability
Research
McMaster University
Hamilton, Ontario, Canada
Danise Levine, March, AIA, CAPS
Architect and Assistant Director, IDeA Center
School of Architecture and Planning
University at Buffalo
Buffalo, New York
Rachel Russell, PhD
Occupational Therapist
Salford University
Salford, England
Dory Sabata, OTD, OTR/L, SCEM, FAOTA
Clinical Assistant Professor
University of Kansas Medical Centre
Department of Occupational Therapy Education
Kansas City, Kansas
John P. S. Salmen, FAIA, CAE
President of Universal Designers & Consultants, Inc.
Silver Spring, Maryland
Bevin Shard, Assoc Dip App Sc Building
Former Superintendent Representative in Queensland
Government
Builder
North Ipswich, Queensland, Australia
Nicholas Smith,
Occupational Therapist
Housing and Homelessness Services
Queensland Department of Housing and Public Works
Brisbane, Queensland, Australia
Jonathan Ward, BDesSt
Architect
Australia
Amy Wagenfeld, PhD, OTR/L, SCEM, CAPS, FAOTA
Assistant Professor
Department of Occupational Therapy
Western Michigan University
Kalamazoo, Michigan
PREFACE
With the integration of people with disabilities into society, there has been increasing interest in modifying homes to enable them to live independently in the community. The aging population has also raised
concerns about how well homes can support people’s health and safety as they age. Occupational therapists
have been identified as having the skills and knowledge to assess the modification needs of these clients,
including consideration of their current and future requirements and the nature and use of the home environment. However, to be effective, therapists also need to understand the technical aspects of the built
environment, design approaches, and the application of a range of products and finishes to determine
appropriate modification solutions. This book aims to provide therapists with all the knowledge and skills
they need to effectively provide home modification recommendations.
In this book, we use a transactional approach to examine the person-occupation-environment interaction
and provide therapists with a detailed understanding of the various dimensions of the home environment
that impact on home modification decisions. We also examine the context of home modification services and
the impact of various demographic, legislative, policy, and service delivery traditions on the development
and delivery of home modification services. In particular, we explore the roles and perspectives of each
stakeholder in the home modification process, and we present a range of strategies to assist occupational
therapists to achieve effective and positive service delivery outcomes. Additionally, we review the current
legislative environment and the funding schemes that facilitate service delivery. We examine, in detail, the
home modification process, including a review of approaches to evaluating, measuring, and drawing the
environment; identifying and evaluating interventions; applying design standards; and reporting and legal
issues. To assist the reader in identifying bases for evidence-based practice and topics for future research
and theory development, we provide an overview of the literature on evaluating home modification outcomes and review the evidence for home modification interventions. The book concludes with a series of
case studies that highlight the application of the home modification process in developing effective solutions for a range of client groups.
Our challenge in developing this text has been to provide a textbook that not only presents the theory
relating to the person-occupation-environment transaction, but also one that provides therapists with
the information they need to examine and influence this transaction. This knowledge has been acquired
through years of extensive clinical, educational, and research experience in home modification practice
and in training undergraduate, graduate, and postgraduate occupational therapy students as well as novice
and experienced practitioners. This book provides us with an opportunity to share our expertise and years
of experience of working with older people and people with disabilities to identify their home modification
requirements. In addition, our experience as supervising practitioners working in the field has enabled us
to identify the essential learning needs of occupational therapists providing home modification services.
To date, the small amount of the literature in this field has been based solely on expert opinion. This book
emerges from a solid theoretical foundation to provide practical real-life applications and strategies. It also
provides a framework for examining the efficacy of home modification practice, shaping future research
using evidence in practice.
Home modification practice is of interest in many countries around the world today. This book capitalizes
on this international interest by focusing on the theory, knowledge, and skills that cross borders. People
who require modifications to their homes face similar issues across the world. Similarly, occupational therapists worldwide are concerned with optimizing occupational performance and ensuring that people can
live safely, independently, and comfortably in their own homes. This book seeks to address these universal
issues while acknowledging the legislative and funding contexts that shape service delivery in respective
countries.
We have written this book to meet the needs of students and clinicians from a range of settings. It is often
challenging for students when translating general theoretical principles, which are outlined in generic occupational therapy texts, into practice. Particularly difficult is balancing the many complexities when working
in the home environment—how to work collaboratively with the client to develop a mutually acceptable
outcome and how to utilize scientific, narrative, pragmatic, ethical and interactive reasoning to develop
an effective intervention. In this text, we discuss how to consider the physical, personal, social, temporal,
occupational, and societal dimensions of the home in decision making and provide students with a systematic process for identifying and evaluating home-based interventions. The practical application of theory,
xvi
Preface
legislation, and standards is a strong focus of the information presented and will equip student occupational
therapists to work with people with a broad range of disabilities and to implement an occupational therapy
process in the home environment. It takes them systematically through the process in a detailed and
practical way, which is often not provided in generic occupational therapy texts. This book also supports
students on clinical placement and those new graduates who find themselves in practice with foundation
knowledge and skills but who are keen to acquire a deeper understanding of how to deal with the complexities they face in various settings. Although students are provided with an overview of knowledge required
for practice during university training, it is not until they are faced with real-world practice situations that
they understand the importance of the information presented in class and are ready to integrate the detail
that is provided in this text.
This text also provides practitioners with tools and resources for home modification practice. We have
provided several comprehensive case studies to assist novice therapists to understand the range of issues
they need to consider conceptualizing solutions. For experienced therapists, we have provided theory and
practical detail that draws on research and international literature to affirm and refine their practice. The
depth of this book also supports practicing therapists by providing a rich and detailed description of the
issues they encounter in day-to-day practice. It draws on the expertise of clinicians with extensive experience in providing interventions in the home and reviews international legislative and service systems,
research, and literature to support practice. The text also encourages experienced therapists to develop
structures to systematically gather information on the outcomes of home modification practice to ensure
good outcomes for clients, to refine occupational therapy intervention, and to build a body of evidence to
support this field of practice. This information will assist them in continuous improvement of service delivery and in advocating for the systemic change required to achieve good home modification outcomes for
individuals, groups and populations.
This book provides a range of resources and tools, and it can be used as a teaching aid to support students, interns, and novice therapists or as a manual for more experienced home modification practitioners.
The case studies also expose therapists to scenarios that they may not have encountered and broaden their
knowledge base to inform future practice with a range of client groups. The book is unique in that it strongly
focuses on the practical application of theory and research in day-to-day practice, working toward enabling
people to stay in their homes and communities.
In identifying contributors for the book, one of our goals was to draw on the views of experts practicing
in the field to bring a breadth of perspectives to the discussion about how to undertake home modification
practice. Although occupational therapists might experience limitations in their home modification practice
because of a lack of funding or the requirements of the service in which they work, we hope that the theory
presented in this book will stimulate interesting and lively thinking and promote discussion about future
research and practice in the field. An Instructor’s Manual and a series of presentations, based on the content
of this book, has been developed for use by students and clinicians to enable them to further reflect on and
learn from their practice.
Home modification practice is a dynamic and evolving area of practice, and we see this book as a starting
point for the future development of occupational therapy knowledge and skill. We welcome comments and
contributions to further inform this area of practice.
Elizabeth Ainsworth, MOccThy, Grad Cert Health Sci
Desleigh de Jonge, MPhil (OccThy), Grad Cert Soc Sci
FOREWORD
As our population ages and the number of people with chronic disease and disability increases, the
occupational therapist has a major role in creating livable environments that support the everyday lives of
people and support those who provide care for individuals that have experienced occupational performance
problems. We are very fortunate that the team of Elizabeth Ainsworth and Desleigh de Jonge have again
joined forces to edit a second edition of An Occupational Therapist’s Guide to Home Modification Practice.
All of us have created living environments that support our daily lives. Many people’s lives have been
interrupted by disease, trauma, or disability, and those interruptions need knowledgeable occupational
therapists to help them develop strategies and alter their environments so they can care for themselves and
engage with their friends and families, work, and engage in their communities.
This is the book that employs an occupational therapist’s lens and very specific information to prepare
the occupational therapist for assessing client and family needs to create the best possible environments to
support independence and participation. The information in this book will be valuable to practitioners who
need information to work with families prior to hospital or rehabilitation discharge. The depth of the book
will prepare clinicians to work with architectural and engineering firms as a consultant to address the design
issues that will support the needs of their client. The book will also prepare the practitioner who wants to
work with community planners to work at a population level as more emphasis is placed on universal design
and preparation for a normative environment for older adults who will need their mobility, sensory, and
cognitive needs addressed without obvious alterations.
I am excited that knowledge is evolving in this area of occupational therapy practice that requires a second edition of the book. I want to repeat a reference and comment I made when I wrote the foreword for the
first edition 8 years ago. Stegner (1992) asked us to consider space as a container of experiences and remind
us that no space is a place until that which happens in it is remembered. Occupational therapists are the
enablers that help clients maximize their experiences in their space to move in it, function in it, be safe in it,
and, when there are problems, identify and remove barriers that compromise it.
The editors and authors of chapters in this book fit the qualifications of extreme excellence. When we
look for guidance, we look to people with both knowledge and experience. Occupational therapists in
Australia have worked for the Department of Housing serving the Queensland State Government for well
over a decade. Many of them are the authors of chapters in this book. As more and more policy worldwide
is focused on health, safety, and well-being, occupational therapists bring the unique perspective of fostering social participation to this initiative. Actually, occupational therapists are leaders in this work, and this
book gives us the tools to lead in this movement.
Reference
Stegner, W. (1992). The sense of place. In W. Stegner (Ed.), Where the bluebird sings to the lemonade springs (pp. 199-206). New York,
NY: Random House
Carolyn Baum, PhD, OTR/L, FAOTA
Elias Michael Director and Professor
Occupational Therapy, Neurology and Social Work
Program in Occupational Therapy
Washington University School of Medicine
St. Louis, Missouri
1
The Home Environment
Tammy Aplin, PhD, BOccThy (Hons) and
Bronwyn Tanner, BOccThy, Grad Cert Occ Thy, Grad Cert Soc Planning, MPhil
Ô Explain how home environments become places of significance and meaning
Occupational therapists play a key role in recommending modifications to the physical home
environment, usually to enhance a person’s occupational performance, health, safety, independence,
and well-being. Yet as a profession, we have given
little consideration to the meaning that this unique
context has for our clients or to the impact that
these changes may have on their experience of
home. Drawing from recent occupational therapy
literature and the disciplines of environmental psychology and gerontology, this chapter explores the
nature of home and then presents a framework for
considering the experience of home, describing the
physical, personal, occupational, social, temporal,
cultural, and societal dimensions that occur when
one engages with or occupies the home environment. The relationship between a person and their
dwelling is unique and complex, and it is important
that therapists understand and acknowledge the
nature of this relationship if they are to successfully
negotiate changes.
CHAPTER OBJECTIVES
By the end of this chapter the reader will be able
Ô Describe the role of person-environment transactions in the creation of home as a place of
being, doing, becoming, and belonging
Ô Describe his or her own personal experience of
home, including values and beliefs about home
and how this may affect home assessments
Ô Outline the various dimensions of the experience of home
Ô Utilize these dimensions of experience when
exploring client needs, concerns, and requests
during the home modification process
Ô Interpret how the experience of home may
affect occupational therapy practice, in particular, decisions made about changes to the
home environment
INTRODUCTION: DEFINING HOME
“The ache for home lives in all of us, the safe place
where we can go as we are and not be questioned.”
Maya Angelou (1986).
to:
-1-
Ainsworth, E., & de Jonge, D. An Occupational Therapist’s
Guide to Home Modification Practice, Second Edition (pp. 1-15).
© 2019 SLACK Incorporated.
2
Chapter 1
The use of the word home in our general vocabulary is so commonplace and unconscious that it
almost defies definition. In a sense, it is an archetype—a concept that seems to represent something
universal to human nature, as indicated in the
quote from Maya Angelou. For centuries poets and
songwriters have utilized the nostalgic and emotional response that this one word evokes. If you
were asked to write a list of words that reflected
what “home” means to you, your response may
include comfort, support, intimacy, belonging, family, and safety. Although many of us may have similar responses, the experience of home is a deeply
personal experience and concept. “Home” is used to
denote a range of places and meanings. It can evoke
images of the home we currently live in, a childhood
home, a hometown, or a home country.
Historically the concept of home has been widely
researched, and a proliferation of writing exists
within the areas of sociology, anthropology, psychology, human geography, architecture, and philosophy. The concept of home and its meaning in
theoretical, social, and cultural contexts has also
been the focus of several decades of research in
the fields of environmental psychology and gerontology. Although there exists within the literature
“pronounced conceptual and empirical diversity”
about the meaning of home (Oswald & Wahl, 2005,
p. 21), many researchers argue that, in essence,
home is a relationship created between an individual
and his or her environment in which the individual
attaches psychological, social, and cultural significance and meaning to objects and spaces (Dovey,
1985; Hasselkus, 2011; Moore, 2000; Werner, Altman,
& Oxley, 1985). In other words, when we talk about
a “house” we are speaking of a dwelling place, but
when we talk of “home” we are often speaking of
a relationship between an individual and a setting
(Felix, De Haan, Vaandrager, & Koelen, 2015). Rowles
and Bernard (2013) emphasize this critical distinction between physical living spaces such as houses
and apartments and home. They propose that a
dwelling place is an empty space or location without
meaning that only becomes a home when the space
is claimed and afforded meaning by an individual or
a group through habitation. It is this understanding
of home that will be the focus of this chapter.
Home as Place
Within environmental psychology and gerontology literature, much of the writing about the concept of home is based on the premise that people
live in worlds of meaning. An example of this is the
idea of space and place. Space is a neutral physical
dimension that lacks meaning, whereas places are
spaces that have been shaped and transformed by
human events and interaction into places of meaning (Hasselkus, 2011; Mayes, Cant & Clemson, 2011;
Rowles & Bernard, 2013). Places hold the memories
of personal experiences and have personal meaning in the context of ongoing life (Hasselkus, 2011;
Rowles & Bernard, 2013). Throughout life, people
interact with their social and physical environments
and create “meaningful representations of the self
within the environment” (Oswald & Wahl, 2005, p.
23). Frankel (1978, as cited in Hasselkus, 2011) suggested that the search for and creation of meaning is
an essentially human characteristic. The meanings
that individuals give to experiences and contexts
are influenced by their own unique needs, goals, histories, and experiences, as well as shared social and
cultural understandings and knowledge. In attributing such meaning, people make sense of their life
experiences (Hasselkus, 2011; Rubinstein, 1989).
The creation of place as a context of personal
meaning usually comes about through action. Rowles
and Bernard (2013) outline three key elements in
the process of transforming space into place. First,
there is the use of an environment—usually through
repeated patterns of habitual behavior, such as daily
routines that make up everyday life. Through the
repeated routine use of a physical space, people
develop an intimacy with the physical aspects of the
home environment—a “physical insideness” (Dovey,
1985, p. 362). Rowles and Bernard (2013) refer to this
“insideness” as a cognitive awareness of the physical
home environment, and this is the second element
in the process of creating place. This “profound
sense of familiarity” is often unconscious and only
becomes apparent when threatened or destroyed
(Dovey, 1985, p. 362). The final element in the process of place-making is the emotional attachment
and sense of ownership that develop for the individual through the use and awareness of familiar and
known spaces (Rowles & Bernard, 2013).
This transformation of space into place can occur
across a range of frequently used settings such as
a regular table in a frequented café or restaurant
or a favorite chair in the local library. However,
the home environment is likely to be the strongest
experience of place as it involves an “intimate
interweaving of person and location over time”
(Rowles & Bernard, 2013, p. 11). For many people,
the creation of home and emotional attachment
to a dwelling occur because of some action on the
physical environment, such as personalizing a space
by putting up objects of personal value, or creating
new spaces, such as a garden. In acting on the environment, a person establishes a history of being “in
place” and spaces take on a significance that they
previously did not have for the individual. Home, as
The Home Environment
a relationship, is created through the transactions
that occur between individuals and the environment
where action results in the creation of meaning
(Dovey, 1985). This idea of acting on and being acted
upon is at the heart of a transactional approach to
people and environments.
Person-Environment Transactions:
The Heart of Home
A transactional view of people and their contexts
has been explored by philosophers such as John
Dewey (Bunting, 2016) and was adopted by environmental psychologists to explain the relationship
between people and their contexts. As outlined in
environmental psychology, a transactional approach
interprets the interaction between a person and
their environment or context as something that
is dynamic and always changing. The person and
context can only be understood when examined
together as a unified system (Werner et al., 1985).
Trying to gain knowledge or understanding about
the person as separate from the context in which
they live and act is a meaningless exercise because
the two elements (person and context) are interwoven and interdependent (Altmann, Brown, Staples,
& Werner, 1992). Within a transactional approach,
the term context refers to much more than just the
physical surroundings and encompasses personal,
social, cultural, and political aspects.
To illustrate this, consider the case of an older
woman in a hospital who is being considered for
discharge to her home following a stroke. In therapy,
she can manage three to four steps easily with the
assistance of one person. A pre-discharge visit to
the home reveals an entrance with two to three
steps. As part of her discharge plan, education is
provided to her husband regarding how to aid her
when using steps in the hospital. Based on her performance in the hospital, she is deemed to be safe to
manage the steps at home and is discharged. When
the community health team visits a few weeks after
discharge, however, they find that she has not been
able to leave the house, as she is unable to use the
two to three steps. Why is her performance at home
different from what she was doing in the hospital?
She has not deteriorated physically, but the context
has changed. In the first place, the steps of her home
have a slightly higher rise than those in the hospital,
creating a greater level of difficulty. This, however,
was not the only reason. In the hospital, she was
either assisted or supervised by a trained aide or
therapist who provided her with encouragement and
confidence when undertaking the task of climbing
stairs. In her home context, her husband did not feel
3
comfortable assisting her, partly because of a lack
of experience but also because assisting his wife
was not in line with his cultural expectations. Both
husband and wife came from a cultural background
where the wife was the one who gave assistance,
and this had been her role up until her stroke. He
therefore was neither comfortable nor willing to take
on the role of her assistant, and she was unable to
use the steps without his help. The approach taken
in discharging this woman was to assume that her
performance (managing two to three stairs) in the
hospital would be the same in the home context. A
transactional approach would not assume that a person’s performance or behavior would be the same if
the environment or context changed. A different context is highly likely to result in a different outcome as
the nature of person-environment transactions are
dynamic and interdependent.
In addition to seeing people and contexts as interrelated and interwoven, a key defining feature of a
transactional perspective is the realization that person-environment transactions are both observable
and unobservable. Transactions occur at the level
of observable actions (activities, tasks, routines,
rituals) and through unobservable psychosocial
processes by which people evaluate, interpret, and
ascribe meaning to their experiences (Werner et al.,
1985).
This understanding of person-environment transactions has formed the basis of many occupational therapy frameworks that focus on occupational performance such as the Person-EnvironmentOccupational Model (Law et al., 1996), the Model of
Human Occupation (Keilhofner, 2002), the Ecological
Model of Occupation (Dunn, Brown, & Youngstrom,
2003), the Person-Environment Occupational
Performance Model (Baum, Christiansen, & Bass,
2015), and the Canadian Model of Occupational
Performance and Engagement (Polatajko, Townsend,
& Craik, 2007; Polatajko et al., 2013). Although these
frameworks acknowledge the dynamic nature of
person-context interactions as well as the “subjective (emotional or psychological) and objective
(physically observable) aspects of performance”
(American Occupational Therapy Association, 2008,
p. 628), in day-to-day practice, occupational therapists are often so focused on the observable, measurable aspects of people acting in their environments
that they are at risk of giving little consideration to
the unobservable meaning-making processes that
occur within the home context.
The focus on observable activity is historically
embedded within the occupational therapy profession (Hasselkus, 2011). Although finding a universally agreed definition is difficult, occupation has
4
Chapter 1
often been “categorized as everything people do to
occupy themselves, including looking after themselves (self-care), enjoying life (leisure), and contributing to the social and economic fabric of their
communities (productivity)” (Canadian Association
of Occupational Therapy, 2002, p. 34). This focus on
“doing” has been “inadequate to address issues of
meaning in people’s lives” (Hammel, 2004, p. 296),
and recent theorists have challenged traditional
understandings of occupation.
Occupation: Doing, Being,
Belonging, Becoming
Wilcock and Hocking (2015) present a conceptual
model of occupation in relation to health comprising
four elements: doing, being, belonging, and becoming. Doing relates to the observable elements of
occupation and is a central and familiar aspect of
our professional practice (Hitch, Peppin, & Stagnitti,
2014). Being is the sense of personal existence,
supported by beliefs and values. It is the personal
aspect of occupation and is often experienced as
a quiet time of thinking and reflection (Wilcock
& Hocking, 2015). Although linked to doing, being
can be independent of occupational engagement, a
time to sit with emotions or simply exist (Hitch et
al., 2014). Belonging pertains to the social aspects
of occupation—being a part of groups, communities, and places. It relates to the idea of being a part
of something bigger than oneself, of friendship,
affirmation, and mutual support (Hitch et al., 2014).
Becoming relates to the notions of change, development, and transformation over time. For some
people (e.g., those with a chronic illness) becoming
may not always mean improvement; it can also mean
maintaining or even managing over time as a condition progresses.
Although only briefly outlined here, this view of
occupation aligns well with the perspective that
views transactions as both observable and unobservable meaning-making processes. As occupational therapists, we observe and assess the day-to-day
routines and habits that people “do” as part of their
daily occupations in their home environments. It is
important to realize that even the most mundane
“doing” has elements of “being.” How we structure
our daily routines—the way we make the bed, clean
our teeth, when we shower—all have some connection to our sense of who we are, or the “being” side of
occupation. Even small changes to these elements of
“doing” can dramatically affect “being,” “belonging,”
and even “becoming.”
Within the context of home, a focus on the
observable, doing elements of person-environment
transactions alone can significantly affect the relationship that exists between a person and his or her
home and can detract from the meaning of home to
an individual (Aplin, de Jonge, & Gustafsson, 2015;
Hawkins & Stewart, 2002; Heywood, 2005; Tanner,
Tilse, & de Jonge, 2008). It is therefore essential that
occupational therapists working within the home
environment and those engaged in recommending
alterations to that environment understand the place
that is home and the possible impact that they may
have on this domain of significant personal meaning.
UNDERSTANDING THE EXPERIENCE
OF HOME: THE DIMENSIONS OF
THE HOME FRAMEWORK
For many occupational therapists, their place of
work and the focus of their intervention is the client’s home environment. This is particularly true of
therapists working in the field of home modifications;
however, to date, there has been limited information
in our professional literature about this particular
context and the impact our interventions have on a
person’s experience of his or her home environment.
When the home environment has been examined,
researchers have referred to the experience of home
as occurring across various domains (Hayward,
1975; Sixsmith, 1986; Smith, 1994). Recent work,
involving a review of the literature base, and a substantive qualitative study aimed to build upon this
earlier work to provide a comprehensive framework
for understanding the experience of home. The physical, personal, social, temporal, occupational, and
societal dimensions were identified to contribute to
the experience of home (Figure 1-1; Aplin, de Jonge
& Gustafsson, 2013, 2015). The physical, personal,
and social dimensions were previously well-established core dimensions of the home environment
(Oswald & Wahl, 2005; Sixsmith, 1986; Tanner et al.,
2008). The temporal and occupational dimensions,
although not as well described, were also previously
defined in occupational therapy, architecture, gerontology and environmental psychology literature as
contributing to the experience of home (de Jonge,
Jones, Phillips, & Chung, 2011; Despres, 1991; Haak,
Dahlin-Ivanoff, Fänge, Sixsmith, & Iwarsson, 2007;
Hayward, 1977; Sixsmith, 1986; Tanner et al., 2008).
The societal dimension had not been previously
clearly described in the literature. This dimension
acknowledges the macro environment and its influence on the meaning of home (Aplin et al., 2015) and
is a context that the literature had previously been
critiqued for its bias in ignoring (Despres, 1991).
The Home Environment
5
Figure 1-1. Six dimensions of home.
The Dimensions of Home Framework was developed to provide a way to understand each person’s
unique experience of home and the various dimensions that contribute to this experience. It seeks to
make explicit the various aspects of person-environment transactions by describing unobservable
as well as observable aspects of the home environment so that therapists might develop a deeper
understanding of each client’s unique and personal
experience of home. The relative importance of each
of these dimensions will differ from individual to
individual and is influenced by the cultural context.
Individual priorities will also change over time as
life circumstance, values, and roles change. When
considering the experience of home for our clients, it
is important to understand the dimensions of home
that are most important now, how this might change
in the future, and what compromises and trade-offs
are acceptable.
The Physical Dimension
The physical home is concerned with the idea of
real space—the raw material from which the dweller
builds a home. Professional education and training alert occupational therapists to the physical
environment, and it is therefore the dimension with
which occupational therapists are most familiar.
Literature outside of occupational therapy, from gerontology and psychology examining the home environment and its meaning, also identify the physical
dimension as important in understanding the experience of home (Despres, 1991; Oswald & Wahl, 2005;
Sixsmith, 1986; Smith, 1994).
The interconnected nature of the dimensions of
home is demonstrated by the physical dimension,
as it both influences and is influenced by the other
dimensions. Consider the changes that people might
make to their home, such as a new kitchen, an extra
bedroom, or a deck or patio. While these are physical changes, the motivations for and the considerations required when making these changes reflect
the wider dimensions. The addition of another room,
for example, may be important to create a study area
(occupational dimension) or a room for friends and
family to be able to stay overnight (social dimension). A deck may be added to provide an entertaining area to socialize (social dimension).
The importance of the physical dimension and its
influence on the experience of home is illustrated by
the fact that when people describe negative experiences of home, it is most commonly in relation to the
physical aspects (Smith, 1994). To illustrate this, consider the case of Janice. Janice lived in a small social
6
Chapter 1
housing studio unit and had previously been close to
homelessness. Her experience of her current home,
however, was one of discomfort that affected her
well-being. The small space meant she was unable
to have friends or family over for dinner and unable
to have her granddaughter visit and stay overnight.
These were dearly missed occupations. At times, she
found the ambience of the house unbearable. She
felt closeted in the small space. It was dark, and the
smell of cigarette smoke had seeped into the brick
walls from a previous tenant, affecting her sleep. She
described her home as a “big dark coffin.” Janice’s
story demonstrates that the physical aspects of
home are powerful, influencing our day-to-day comfort and well-being. Most people are aware of this
impact, as evidenced by the simple changes many
of us make to our homes, such as painting a room,
adding new furniture, tidying up, or adding a garden,
which often enhances our experience of home.
The physical dimension has been conceptualized
as having four elements (Aplin et al., 2013, 2015).
These are (1) the structure, services, and facilities;
(2) space; (3) ambient conditions; and (4) the location of home.
Structure, Services, and Facilities
The structure of the home refers to the raw structural elements such as the roof, floor, and walls, and
the materials and finishes such as flooring and paint.
This element of the physical dimension also includes
the fittings and fixtures such as taps, sinks, and cupboards (de Jonge, 2011; Sanford & Bruce, 2010). The
services and facilities of home include those that
make the home comfortable and usable, such as wiring, plumbing, air conditioning, and ventilation (de
Jonge, 2011). Other examples of services and facilities include internet access, rubbish removal, and
sewage. Seemingly “nonessential” features might
include a pool or smart technology features such as
automated lights, doors, and blinds.
Space
The space in and around the home influences
what we do and our comfort at home. If you have
ever lived in a small home with many people, you
will know that it can be difficult to find a quiet or
private space. The amount of space is determined
by the layout and orientation of structures and
furniture within the home (Hayward, 1975; Sanford
& Bruce, 2010). For example, a room with windows
and doors on every wall affects the usability of the
space, making it difficult to fit in all the furniture.
Our need for space changes over time. The space
required for a single person compared to couple or
a family of five or six is different. This need for more
or less space is often a driving factor in relocating.
For example, a larger home is needed when a family
grows or a smaller home is needed when older adults
are wanting to downsize.
Storage space is another important factor. A lack
of storage space often means the usable space in
rooms and walkways is reduced to accommodate
extra pieces of furniture, equipment, and belongings.
Storage space can often be overlooked when considering renovation or modification. Yet, for many
people, it is critical, as insufficient storage space
often results in clutter that affects the experience of
home and subjective well-being (Roster, Ferrari, &
Jurkat, 2016).
The space needed to store and maneuver equipment can require significant modification and frequently makes relocating necessary. This is often
the case for families of children with disabilities,
who speak of the arduous decision of whether to
modify their existing home or move to something
more accessible. If they choose to modify, however,
the enhanced space can make important changes
to daily life in the home, enabling freedom of movement, enhancing privacy, or facilitating relationships that may have been harmed by a lack of space
(Heywood, 2005).
Ambient Conditions
The ambient conditions include those aspects of
the home that can bring comfort and enjoyment, creating our favorite places where we sit in the morning
sun or enjoy the view out of a window. Occupations
like these of rest and relaxation in an enjoyed place
reflect the “being” aspects of occupation that are
important in creating a positive experience of home.
Ambient conditions include lighting, airflow and
breezes, shade, a view, sound, and the weather or
the climatic impact on the temperature and comfort
of the home (Aplin et al., 2013; Sanford & Bruce,
2010). In the earlier description of Janice’s experience of home, her poor experience was in part due
to the darkness and smell of her home. For a number
of people, noise can also be a significant barrier to
their enjoyment of home, such as noise from a busy
road. The significance of the ambient aspects of our
homes is often highlighted only when they are lost or
negatively experienced. Before I moved into my current home, I lived in a unit that overlooked a vacant
large block of land. My view was of trees and birdlife.
While I was living there, it was cleared for a unit
development. I had not realized how much I enjoyed
my view until it was gone. My view was replaced with
overcrowded back decks used to store items such as
washing lines, bikes, and boxes that did not fit into
the small flats. The sounds also changed, from birds
and running water to the private conversations of
neighbors, children, and cars.
The Home Environment
Location of Home
The location of home relates to its position within
the neighborhood, in the street, and on the site.
Location is a particularly important physical aspect
of home and is often a key priority when we are looking to rent or purchase an existing home or build a
new home. Location considerations such as the climate; the topography or lay of the land; and the proximity to family, friends, local services and facilities
such as shops, doctors, recreational activities, and
transport contribute to our quality of life (DahlinIvanoff, Haak, Fänge, & Iwarsson, 2007; Despres,
1991). Where we live with regard to the climate
influences our day-to-day activities and the design,
services, and facilities in our homes. When living in
a cold climate, heating and insulation are a priority.
In warmer climates, ventilation and air conditioning
are important, along with outdoor living spaces for
socializing. The topography of the area may also
influence the activities that can be undertaken. For
example, older adults who live in hilly areas may
experience limitations to participation if they are
unable to walk to the local shop, doctor, or bus stop.
Consider the significant impact location would have
on your daily life if you had no control or choice
over where you lived. In a research interview, Joan
and Greg expressed their disappointment over the
location of their dwelling. As social housing tenants,
they were given little choice in their location, and
their house was a great distance from their family
and grandchildren whom they had been supporting
and visiting regularly prior to the move. The move to
a new location resulted in a loss of important social
roles and reduced family engagement.
The Personal Dimension
The personal dimension assumes an emotionally based, meaningful relationship exists between
an individual and his or her dwelling place (Dovey,
1985; Moore, 2000). This dimension captures those
aspects that transform a physical dwelling place into
a home where we experience security, comfort, and
a place to belong. Our emotional relationship with
home is complex, individual, and linked to our history and values. Four aspects to the personal dimension of home have been identified in the literature
and home modification research, including (1) safety
and security; (2) privacy; (3) control, freedom, and
independence; and (4) identity and connectedness
(Aplin et al., 2013).
Safety and Security
Home should be where we feel most safe; it is a
haven from the outside world, a place of security and
7
comfort. For this “safe haven” to exist, a place for
retreat, refreshment, and relaxation, we must have
control over the home to keep intrusions from the
public or “outside” separate to the private or “inside”
domain. Our sense of safety and security at home is
both physical and emotional. The physical aspects,
which contribute to the sense of safety and security,
include the physical structure of the home, the functionality and ease of use of the home amenities, and
living in a familiar neighborhood with help at hand
if needed (Dahlin-Ivanoff et al., 2007; Smith, 1994).
For example, some people feel more secure or safe
in a brick home compared to a timber home. For others, having security screens and being high off the
ground can feel safer. The presence of supportive
neighbors, or having neighbors who will “keep an
eye on things,” can also make a big difference to how
secure we feel in our home and neighborhood.
Emotionally, feeling secure in our home is associated with the sense of permanence and familiarity that home can bring (Dahlin-Ivanoff et al., 2007;
Sebba & Churchman, 1986; Sixsmith, 1986). Home
ownership is a goal for many and reflects the sense
of security that comes from having a permanent
home—a home that you have control over and
where you can make plans for the future. In contrast,
many people who rent experience poor security of
tenure, requiring them to move if the owner chooses
to sell, for example. This lack of secure tenure is recognized as a cause of stress and threat to a renter’s
well-being (Lewis, 2006).
Continuity and the memories associated with
the home are also important in contributing to the
sense of security (Dahlin-Ivanoff et al., 2007; Sebba &
Churman, 1986; Smith, 1994). Living in one place for
many years, feeling a part of the place, and growing
old in one place create security and comfort in daily
life. Compare this to when you move to a new location, the sense of familiarity and security can be initially lost and daily stress might increase due to the
simple things being difficult (e.g., not knowing how to
get to the local shop or how to use public transport).
Privacy
Privacy has been described as having an important contribution to the experience of home (Smith,
1994; Tognali, 1987; Zingmark, Norberg & Sandman,
1995). Home is our most private space, and it is only
when we are able to control the access of others, our
social interactions, and space that privacy is afforded to us (Gifford, 2002). In our homes, there are both
public and private spaces, which can differ for each
household and different family members (Sebba &
Churchman, 1986). For example, the bathroom may
be a shared space, but private for all at certain times.
8
Chapter 1
In some households, bedrooms are private for parents and caregivers but not for children.
The significance of privacy within the home is
most strongly felt when it is not present, with negative experiences of home associated with a lack of
privacy and freedom (Smith, 1994). These include,
for example, a lack of control over social interactions, having intrusive flat mates or guests, lacking
a space of one’s own, or lacking privacy from the
street (Smith, 1994). These experiences are common
and illustrate the importance of privacy to achieve
a positive experience of home. For adults receiving
formal caregiver support in the home, privacy can
often be lost, with the home no longer being a private space, but a workplace for staff (Lund & Nygard,
2004). There may be a loss of control over not only
who is in the home, but also the control of private
spaces and activities, such as bathing and toileting.
The impact of support workers on the experience of
home can be dramatic. Craig and Susan’s experience
reflects this. They were a couple who lived together
and had daily paid workers coming into their home
to assist Craig with his self-care activities. They
described their experience of having paid support
workers in the home as feeling like their home had
been invaded. They felt their home had become
institutionalized and their privacy was continually
compromised by the presence of support workers.
Additionally, workplace health and safety requirements of the service provider had reduced Craig’s
independence, requiring him to use more equipment.
Overall, Craig felt as though his home had become
more of a workplace than a home. Craig and Susan’s
story demonstrates the significance of privacy in
the home, as their loss of privacy and control significantly altered their relationship with their home.
This loss was keenly felt by Craig, who had lived in
his home for over 18 years and which had previously
been a symbol of his independence.
Control, Freedom, and Independence
Privacy is closely linked to our sense of control and freedom at home, as we need control to
have the privacy we desire (Gifford, 2002). As a
refuge from the outside world, our home is where
we should have control and independence, free to
make our own choices and actions (Despres, 1991).
Control has been described as an important aspect
of the experience of home (Oswald and Wahl, 2005;
Sixsmith, 1986; Tanner et al., 2008). It is central to
our experience, as control over our home and access
to ourselves creates privacy, facilitates a sense of
security, permits routines and order to develop, and
allows us to personalize and create a home that is
our own (Despres, 1991; Smith, 1994; Zingmark et
al., 1995). For many, the first move out of the family
home into your own home brings a sense of control and freedom. You have far greater control and
choice over your daily routines, such as when you
have dinner, what you eat, and who you invite into
your home. You are able to choose your own furniture and decorate and use your home space as you
choose. Having a space that you can truly make your
own, a place for yourself, is a freedom that many are
unable to obtain.
For both older adults and people with a disability, home can facilitate independence by providing
control over what they do and when they want to
do it (de Jonge et al., 2011; Heywood, 2005). It is this
presence of control that distinguishes home from
other living situations, specifically institutions. Loss
of control is what people most fear about living in an
institution. In considering the experience of living in
an aged care facility for example, control over many
aspects of life is lost. The choice of location may
be limited, and you may be required to move to an
area not familiar to you. You usually can only bring
limited personal items and have limited choice in
the setup of the room, furniture, or style. It is likely
that you will have no choice over your neighbors
or roommates, or even who sits with you at dinner.
Your daily routine is usually structured by others,
including when you shower, when and what you eat,
and when you can have visitors. Your activity and
mood are recorded, and your life becomes medicalized and monitored. This loss of control in such an
institutional setting is in sharp contrast to what most
of us experience in our home environment and highlights the important role that control plays in our
experience of home.
Identity and Connectedness
Home as a place of identity and connection is the
most personal aspect of home as it is associated
with our sense of self. There is a deepening relationship with home that begins with how we personalize
our homes through self-expression and extends to
the deeper connections of identity and belonging.
We express our style, interests, and values through
our home; it is a reflection of how we want to see ourselves and how we want others to see us (Despres,
1991; Hayward, 1977; Sixsmith, 1986). Our identity is
often reflected in how we decorate and organize our
homes. When we first move into a home, we organize
our personal items, decorate, paint, or renovate. It
is through this process of self-expression that the
physical space of a house or apartment begins to
become a home (Tognali, 1987). Home as a place of
identity represents who we are and is an extension
or embodiment of ourselves (Hayward, 1975, 1977;
The Home Environment
Sixsmith, 1986). This identity is not only associated
with the physical home and its reflection of our
values and style, but also our routines and the history and memories associated with home (Sixsmith,
1986).
Our home connects us to our past. When memories are found in each room and on each corner of
the neighborhood, we form an emotional attachment
to our home, and our sense of identity becomes connected to place, particularly if we have lived there
for some time (Dovey, 1985). This identification with
place over time is particularly important for older
adults. Rowles (1983) describes this identity connected to place as “autobiographical insideness,” or
“being a part of the places of one’s life and of the
places being a part of oneself” (Rowles, 2000, p. 531).
The connection we feel to our homes is also
related to the sense of rootedness and continuity of
home (Hayward, 1975, 1977; Heywood, 2005; Oswald
& Wahl, 2005; Smith, 1994; Tognali, 1987; Zingmark
et al., 1995). Having control over one’s home, a
sense of ownership and permanency, and of knowing it is your place in the world leads to continuity
(Hayward, 1977). It is only over time that this sense
of continuity and rootedness, where home is the center point for life and a place to return to, can develop
(Despres, 1991). Home can therefore lead to a strong
sense of belonging. The story of my grandfather illustrates this deep connection to home. He lived and
worked on the family farm his entire life. He watched
his children and grandchildren play in the same
places where he grew up. His connection to place
extended to the local town, where he had a house
to be close to services when his wife was unwell.
This deep sense of rootedness to place appeared to
create a contentedness in life, the sense of knowing
oneself in the world. There was no uncertainty of
where to be or what to do, he was sure of who he
was and where he belonged. He was grounded and
demonstrated a confidence and calmness in life from
his connection to place.
The introduction of modifications or equipment
can be challenging for many reasons, but some of
the key concerns can be associated with identity and
connection to home. Changes to the home may be
affronting because they look “clinical” or “disabled”
for example, and this is not how the person sees
him- or herself. There can also be important connections and memories associated with furniture,
objects, and the design or fixtures and fittings in a
room that may lead people to be resistant to suggested changes. For example, a colleague told the story
of an older client who needed access to her home.
The most important consideration for the client was
that the front steps were not altered. Her father had
9
built the stairs and, because of this, they retained
strong personal meaning. These concerns related to
aspects of the personal dimension can be difficult
for people to articulate and reflect those unobservable meaningful aspects of home. It is important
that we consider these unobservable aspects when
gathering information about the home and in discussions about recommendations as modifications can
change these deeply personal aspects that contribute to the experience of home.
The Social Dimension
The social dimension refers to the emotional
environment created by relationships with others.
First of all, the social home involves those relationships most significant to the individual, such as a
spouse or family who may live in the same dwelling.
The social dimension also expands beyond this to
include those who enter or occasionally may influence the home, such as relatives, neighbors, friends,
and community networks. These relationships and
connections within the home are central to the
meaning of home (Despres, 1991; Hayward, 1977).
Home is often described as the center of family
life, a place where children grow, learn, and explore
(Somerville, 1997). The childhood home can be a
place with strong emotional connections (Mallet,
2004). The social dimension recognizes that home
is often where our closest relationships occur. It is
the place where these relationships are strengthened and developed, with feelings of love, caring,
and intimacy associated with home (Despres, 1991;
Hayward, 1977). In our homes, we spend time with
family and pets and entertain and socialize with
friends. The importance of good social relationships,
both within and external to the home, is highlighted
when there are negative relationships at home. This
can create an atmosphere of unease, where the
home is no longer the warm and comfortable place
one expects (Sixsmith, 1986).
For older adults, living close to friends, helpful
neighbors, and family is important for a positive
experience of home (de Jonge et al., 2011). For many
people, being close to others, especially those who
are important in their lives, and fulfilling valued
social roles are reasons they stay in their home.
Consequently, it can be the most important aspect
of home for older adults (Tanner, 2011). An example
of this is Betty, reported by Tanner and colleagues
(2008). Betty was in her late 60s and lived in a larger,
older house. She had great difficulty accessing her
home environment, including the front steps and
bathroom. Minor modifications had been made;
however, due to her functional limitations, she was
10
Chapter 1
unable to properly access the bath area and washed
using a basin. When offered new accommodation
that was fully accessible within the same suburb less
than 1 km away from her current home, she chose
to remain in an inconvenient and ill-suited physical
dwelling. The reason for this was to maintain her
ongoing involvement with the local children who
gathered in her front yard each morning to get on the
school bus. As she said,
By them (the children) being here the bus
comes along up the road here, they walk
across to catch it and I know they’re safe
… It makes you feel you’re doing something
even though I’m not really doing anything
… to most of the neighborhood children,
I’m Nana. It doesn’t matter whether they are
related or not. I’m Nana. Even the 18- and
19-year-olds still refer to me as Nana. I’ve
got a very large family! (Tanner et al., 2008,
p. 203)
This valued social role and important social network would have been lost by the move because
the new accommodation was not on the school bus
route (Tanner et al., 2008). This type of social relationship and connection with others is an integral
part of the experience of home, particularly as one
ages. Being able to contribute and do things for others has been found to be important in strengthening
personal identity and the sense of being a valued
part of society (Haak et al., 2007). An absence of
relationships with others, however, can result in
loneliness and isolation for older people, and home
can be experienced as “a prison” (Haak et al., 2007,
p. 99). Thus, the location of home with regard to its
ability to facilitate and sustain social networks and
support valued social roles is an important aspect
of the social dimension and consideration for occupational therapists. It is these meaningful aspects of
the social dimension of home—having family close,
grandchildren being able to visit, being able to provide care for others, and being able to pop in to see a
neighbor for a cup of tea and chat—that are essential
to the meaning of home for many and contribute to
the sense of belonging.
The Temporal Dimension
The temporal dimension highlights the dynamic
and changing nature of home, where occupants’
needs and wants change over time. There are both
cyclical and linear aspects to the temporal dimension of home (Werner et al., 1985). The cyclical
nature of home describes the familiarity, routines,
and order of home, whereas the linear aspects refer
to home in the past, present, and future.
Home as Routine and Order
The home moves through daily, weekly, and annually occurring events and activities. These routines
of life and the order of our homes are personal and
have cultural and social influences (Dovey, 1985).
With these unique influences, each home has its
own order and routine, developed from childhood,
and changing over time as circumstances and preferences change. This influences the placement, storage, and use of household goods and furniture and
the activities that occur in our homes. For example,
cooking may occur indoors or outdoors; food may
be eaten at the table or on the couch. Further,
the routines of home life prescribe the timing and
responsibility of household chores and unique family traditions, such as Christmas, Sunday morning
breakfasts, and birthdays, which can be markedly
different across households. These everyday routines and order of life are most markedly noticed
when a change occurs, such as a new resident in the
house or physical changes to the home as a result
of renovations or a home modification. For some,
particularly older adults who have lived in their
home for decades, the idea of changing a bath to a
level access shower, moving a piece of furniture, or
moving to a different bedroom would be unthinkable. So strong is their sense of order and familiarity
with what is in place that they often cannot explain
why the suggestion is a problem, just that this is the
way things have always been and should not change.
There is a comfort in familiarity, and when these
familiar aspects of the home are combined with an
enjoyed ambience and aesthetic, they can have even
more significance, making change more difficult.
This order to home or the familiarity with the
home environment was described by Rowles (1983)
as physical insideness, where habitual routines and
a familiarity with the home develop over time. This
explains how a home environment, which may seem
unsafe, is easily navigated and compensated for by
older people. Knowing the home environment inside
and out is also described by Rubinstein’s (1989) first
aspect of a person-centered process: accounting.
This physical order of home, as known only by its
occupants, is how people can navigate in the dark
and know where those little-used items are, such as
a flashlight or spare light bulbs.
Sociocultural influences affect the routines and
order of everyday life. For example, traditionally
in Western cultures, men of the household performed outdoor household chores such as mowing
and repairs, whereas women undertook cleaning
and cooking. There can also be shared norms and
social roles within a neighborhood or community.
For example, within a neighborhood, there may be
The Home Environment
shared expectations about garden maintenance or
the appearance of homes. These routines and order
develop over time and therefore can have more
significance to older adults, who have a stronger
attachment to homes they have lived in for some
time (Rowles, 1983).
Home as the Past, Present, and Future
Home is not static but rather constantly adapting with the changing needs and preferences of its
occupants, as well as external societal influences.
Sixsmith (1986) described the home as occurring
within a temporal framework, where the meaning
and needs of home change through different stages
of life, such as childhood, early adulthood, having a
family of one’s own, and retirement. This can sometimes mean a change in home, such as relocating to a
larger home when having more children or downsizing in later life. Sometimes this can be outside of our
control. We may need to move for work or to provide
support for a family member. For many older adults
and people with a disability, this may be a decision
that is forced upon them due to the poor accessibility of their home, a lack of housing, or support services being close by.
The temporal nature of home is closely related
to the personal dimension, providing a connection
to the past through history and memories (Dovey,
1985). The past events of home provide the story of
the home, the significance of objects, features, and
places within the home that are often invisible to the
visitor. The future is also an important consideration
as we often imagine future possibilities through the
lens of our homes or where and how we are living (Dovey, 1985). Our future plans often include
improvements to the home or a move to a new home.
For example, we may move to be closer to friends or
family, to have more space, or to live at the beach or
in the country. In these moves, we aim to facilitate a
more positive experience of home.
The Occupational Dimension
The occupational dimension recognizes the home
as a place of doing, where many of the everyday
activities of life occur and where some of our most
meaningful occupations take place. Literature outside and within occupational therapy highlights
the significance of occupation to home and the
importance of activities performed within the home
contributing to the meaning and value of life at home
and “being” in the home (Rowles, 1991). Home has
been described as a “center” or “base” of activities
supporting work, hobbies, leisure, eating, sleeping,
and recreation (Despres, 1991; Hayward, 1977).
11
In occupational therapy literature, the relationship between occupation and home has been examined closely, with home being identified as a place
for valued and meaningful occupations (de Jonge et
al., 2011; Haak et al., 2007; Heywood, 2005). When
we first consider the home from the perspective of
“doing,” we can understand the home as a hub of
activity. It is where the day-to-day “doing” of our life
occurs, such as getting ready for work or school,
making meals, cleaning, gardening, relaxation, and
rest. This “doing” of the everyday activities of life
(e.g., moving from room to room, getting in and out
of the house, making a meal, using the toilet and
shower, and taking out the trash) should be easily
completed without hassle, fear, or frustration. When
the “doing” at home is easy, the home is a place of
comfort and ease. It is often when we experience
difficulties that the value of this dimension of home
is highlighted. When a home is being renovated, for
example, there is often mud and dirt in the yard, and
planks of timber may be put down so you can access
the house. A camping kitchen may be set up, and a
family of four uses the en suite bathroom while the
main bathroom is not available. “Doing” in this environment becomes stressful, may create tension in
a family, and may negatively affect the comfort and
well-being of those living in the home.
Home modifications have been reported to positively affect the ease of “doing” within the home
environment for older adults, people with a disability, and their family members (Aplin et al., 2015).
The value of this ease to everyday life cannot be
underestimated as difficulty in daily activity can
create a negative experience of home and affect
important aspects of “being.” Consider the story of
Bec. Bec lives in a home with her two adult children.
She had an above-knee amputation and mainly used
a wheelchair for mobility rather than her prosthesis.
Her home had three steps, and her children had built
her a homemade ramp over the steps. Using this
ramp was difficult because it was not fixed, and Bec
required the assistance of both her children when
using it to leave the house. Because of this difficulty,
Bec rarely left her house, mostly staying indoors.
Bec spoke of missing the simple enjoyment of sitting
in the garden, which was her favorite place to spend
time and reflect. Because of the difficulty in daily
“doing,” Bec missed the opportunity to just “be” in
her favorite part of her home. Bec’s story reflects the
importance of both “doing” and “being” and demonstrates that, although being able to do activities in
and around the home is important, feeling “at home”
or simply “being” at home is equally valuable.
The activities performed within the home are
unique and personal and contribute to a sense of
12
Chapter 1
“being.” Whether sitting in the garden, reading a
book in a favorite room, or reflecting on life as you
hang out the washing in the sun, everyone seeks to
find a place of reflection or to simply be with oneself.
These activities are key to creating meaning and
connection and enriching our home life, which contribute to our sense of well-being.
We engage in some of our most enjoyable and valued occupations at home. Leisure activities, hobbies,
or activities that are important to our well-being and
valued roles contribute to our sense of self as we fulfill and experience our identity (Christiansen, 1999).
The story of Andrew reflects the need for our homes
to enable these meaningful occupations. Andrew
worked in music production and used his home as
his office with clients frequently visiting. Andrew’s
bathroom housed a range of mobility and transfer
equipment, which he felt identified him as having a
disability and did not reflect his identity as a professional. He modified his home to have an additional
accessible en suite bathroom that was able to house
his equipment, leaving a bathroom for the use of his
clients that was free of disability-related clutter.
Occupations also provide a means by which we
engage with others within the home (e.g., preparing
food and eating together), or even being a contributing member of the household through tidying
up, taking the bins out, and working in the garden.
These activities build relationships and connections
with others at home and create a sense of belonging. People with a disability, who are often unable
to access spaces or participate in and contribute to
household activities, can find themselves isolated
within the home, thus limiting their opportunities to
belong. For example, if the kitchen, deck, or family
room are inaccessible, people are unable to participate in the daily activities that are part of the fabric
of home life.
The home is also a place of change and growth,
providing opportunities for development, transformation, and, ultimately, “becoming.” People often
seek a home to support their idea of their future
selves, such as buying a home with additional space
for a growing family, a private space for study,
enough land to raise animals, or a basement for
retirement activities. The home, in this realm of
change and growth, can be an important place for
recovery; for example, participants recovering from
stroke found engaging in everyday activities at home
to be important in creating a new sense of fulfillment and “becoming” (Hodson, Aplin, & Gustfasson,
2016). Parents of children with a disability also
seek to provide opportunities for “becoming” within
the home by creating spaces for the child to grow,
explore, develop, and enjoy life (Aplin, Thornton &
Gustafsson, 2017). Parents may modify a bathroom
to allow the child to develop independence in selfcare activities or provide access to the kitchen to
allow the child to make his or her own lunch, building self-reliance and mastery.
The home as a place of occupation is complex,
and it is difficult to observe the meaning and value
that activities have for the individual. As occupational therapists, we are often restricted to focusing
on a limited range of “doing” occupations in the
home, prioritizing self-care, domestic activities, and
community access without a full appreciation of how
these contribute to being, belonging, and becoming. Occupational therapists have a responsibility
to recognize the activities that are meaningful to
their clients and the potential these offer for being,
belonging, and becoming.
The Societal Dimension
Our homes and their meaning in our lives do not
occur in a vacuum. Many external factors influence
the experience of home, such as rental policies,
government housing policies, and the resources we
have available to change our homes. The societal
dimension has emerged in the literature as an important dimension influencing the experience of home
(Aplin et al., 2013, 2015).
The societal dimension recognizes the impact of
political and economic conditions on the resources
and control that people have over their homes (Aplin
et al., 2015). For example, the affordability of homes
is dictated by a range of external factors that influences where and what type of home we live in. Our
home design, and the changes we can make to our
homes, is also determined by a range of building
codes and government guidelines. The impact of the
societal dimension is deeply felt by people who rent.
For renters, the continuity of home life is influenced
by the length of a lease agreement, and control over
the home environment is dictated by the landlord.
The experiences of residents living in social housing
in the United States who were forced to relocate due
to urban renewal policies demonstrate the influence
of the societal dimension. Residents described the
experience of relocation as traumatic due to loss
of community, social networks, and attachment to
place (Fullilove, 2004). Societal factors also affect
older private renters, who often experience difficulty
accessing home modifications, as home modification
services are reluctant to invest in rental homes, and
landlords may oppose the completion of modifications (Jones, de Jonge, & Phillips, 2008).
Government policies significantly impact
the experience of home, influencing funding for
The Home Environment
modifications, the resources available in a local
area, and the planned infrastructure and services to
the home. Government policies also dictate whether
your local area will have suitable community services available to provide in-home support. Further,
national standards such as fire safety or electrical
and plumbing codes that are prescribed by government influence the design of housing, as does the
availability of services involved in modifying, maintaining, and renovating.
UNDERSTANDING THE EXPERIENCE
OF HOME: CULTURE
The dimensions of home described earlier highlight the dynamic and complex nature of it. Within
the literature, culture is not identified as a separate
dimension or influence; rather, that the experience
of home is tied to its cultural context (Lloyd, 2012),
with culture shaping each dimension. For example, when considering the physical dimension, the
design, layout, space, furnishings, and all aspects
of the architecture of the home are influenced by
the prevailing culture, which changes over time.
Modern home design has changed from a segregated
design where the kitchen was a separate workspace
and children shared bedrooms to a more communal
open floor plan with individual bedrooms (Madigan,
Munro, & Smith, 1990). This highlights the cultural
changes of the roles of women and children within
the home over the last century. The routines and
order of the temporal dimension are also largely
culturally influenced. Where we place items in our
home, the type of furniture we have, and how and
when we complete activities in our home are all culturally defined. Culture also influences the societal
dimension. For example, home modifications tend
to have a lower priority than other social and health
service funding, and the funding focus results in
interventions that target activities of daily living and
safety. This is a reflection of Western culture, where
people with a disability and older adults are viewed
from a medical model, which prioritizes basic care
needs over social and psychological needs. This
cultural view of disability also affects the personal
dimension of home, with many modifications having
a clinical appearance with minimal acknowledgment
of aesthetics.
The influence of culture can be seen in the literature describing the experience of home and
home modifications. The descriptions of home have
evolved over time with associated economic, ideological, and cultural changes (Madigan et al., 1990).
A large proportion of this body of work is older and
13
has been widely criticized for its White, Western,
owner-occupier, family focus, with diverse perspectives lacking (Despres, 1991; Mallet, 2004; Zuffery,
2015). Consequently, it has had a largely positive perspective of home, with meanings focused on family,
safety, and belonging (Mallet, 2004). Varying experiences do exist, and although not widely discussed in
the literature, home can be a place of fear and abuse
(Mallett, 2004). A recent study examining how the
lived experience of class, gender, ethnicity, and age
constituted meanings of home for men and women
in Australia found differing experiences for different
cultural groups (Zufferey, 2015). For refugees and
migrants, although they felt safe in Australia, there
was not the sense of cultural and familial belonging
that they associated with home, and that feeling
“at home” occurred when ethnicity and cultural
backgrounds were not in question (Zufferey, 2015).
In contrast, experiences described by middle-class
Australians with no recent family history of migration focused on improving housing circumstances,
renovations, descriptions of the ideal home, and living in good school zones (Zufferey, 2015). This highlights the importance of the cultural context of home
and the need to understand varying experiences
of what makes one feel at home. Understandings
of home have also been criticized for their lack of
viewpoints from Indigenous peoples. For example, it
has been highlighted that the Western view of home
being a single-family dwelling place and a physical
structure is inappropriate for Indigenous Australians
and does not recognize Indigenous mobility or land
as home (Zufferey & Chung, 2015).
It is important that occupational therapists have
an understanding of the influence of culture on the
dimensions of home as it will enable them to practice
in a culturally responsive way. Therapists should
value and prioritize their client’s experiences of
home and participate in collaborative decision making that responds to the needs of those from a different cultural background than their own.
CONCLUSION
In this chapter, we have explored the meaning and
experience of home drawing from environmental
psychology, gerontology, and occupational therapy
literature. The aim in doing so was to provide a
better understanding of the complex, dynamic, and
unique relationship that is “home” and within which
the process of home modification assessment and
intervention takes place.
People live in worlds of meaning and, as such,
change neutral spaces such as a house or apartment
into places of significant personal meaning, shaping
14
Chapter 1
and transforming them into homes. This transformation occurs through transactions between people and
their environments that are both observable actions
(activities, tasks, routines, rituals) and unobservable
psychosocial processes by which people evaluate,
interpret, and ascribe meaning to their experiences.
The Dimensions of Home Framework provides a
way to capture the elements of the experience of
home as a place of significant and unique meaning.
These dimensions provide a clear picture of the
dynamic, complex, and personal environment of
home within which the home modification process
occurs.
Home modifications have the potential to enhance
the experience of home, to provide a place that is
comfortable, enjoyable, and facilitates the unique
way in which we live in our homes. The potential
also exists for home modifications to undermine the
meaning and experience of home for an individual
or family. When the dimensions of home are not
valued or understood in the home modification process, negative outcomes can arise, where clients feel
out of control, frustrated, and live in homes that do
not meet their needs, making day-to-day activities
more difficult or unsafe. This can occur if the physical aspects of accessibility and functionality are
emphasized and the personal and social meanings
of home held by the home dweller are neglected or
disregarded.
The challenge for occupational therapists is to
first be aware of the complexity of experience that
exists in the relationship between a person and their
environment and to understand that the meaning
of home is not only unique and changing, but also
unobservable, not self-conscious, and often taken for
granted until threatened. Having an understanding
of the dimensions that contribute to the experience
of home enables therapists to move beyond a simplistic, functionalist view of person-environment fit
to one that embraces the complexity of what home
means to an individual and, as such, provide modifications and solutions that benefit the client and
enhance their experience of home.
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Approaches to
Service Delivery
2
Bronwyn Tanner, BOccThy, Grad Cert Occ Thy, Grad Cert Soc Planning, MPhil;
Desleigh de Jonge, MPhil (OccThy), Grad Cert Soc Sci; Andrew Jones, BA, MSW, GCE;
Rhonda Phillips, MPhil, BA, Grad Dip; and Jon Pynoos, MCP, PhD
Occupational therapists have long been interested in helping people to live well in their home
environment and have become key stakeholders in
the delivery of home modification services. Toward
the end of the 20th century, a range of home modification services and resources were developed
that enabled occupational therapists to access a
selection of public and private services to address
those needs. A number of factors have influenced
the development and delivery of home modification
services. This chapter aims to provide therapists
with an understanding of the various demographic,
legislative, policy, and service delivery traditions
that have influenced, and will continue to influence,
the development and delivery of home modification
services. The chapter will also examine the roles,
perspectives, and responsibilities of key stakeholders in the home modification process and provide a
range of strategies to assist occupational therapists
achieve effective and positive service delivery outcomes.
CHAPTER OBJECTIVES
By the end of this chapter, the reader will be able
to:
Ô Describe various demographic, legislative, policy, and service delivery traditions that have
influenced the development and provision of
home modification services
Ô Describe the impact of health, community care,
and housing service systems on the way home
modification services are delivered and the
associated implications for occupational therapists and clients of home modification services
INTRODUCTION
As the demographics of societies change, governments and service providers seek to plan for and
respond to the changing needs of the community.
Advances in health care have resulted in increasing
numbers of people surviving significant injuries and
poor health conditions and living into old age. The
soaring costs of health care and the aging population
have impelled governments to establish strategic
directions that allow older people and people with
disabilities to continue to live in their own homes
and communities. Policies such as deinstitutionalization meant that people with disabilities were
integrated back into the community in the latter part
of the 20th century, and “aging-in-place” policies
- 17 -
Ainsworth, E., & de Jonge, D. An Occupational Therapist’s
Guide to Home Modification Practice, Second Edition (pp. 17-40).
© 2019 SLACK Incorporated.
18
Chapter 2
reflect a commitment to helping older people, as
well as people with disabilities who are living longer, to remain in their communities. Developments
in directed care within the disability and aged care
sectors in a number of countries have also resulted
in people determining where and how money is
spent, thus shifting service provision to priorities.
Recent demographic changes and policy developments have affected how funding is allocated across
a number of service systems—health, community
care, and housing—to enable older people and people with disabilities to live safely and independently
in the community. Funding allocation and choice and
control have also stimulated the development of a
range of home modification services. These developments have had a significant impact on the work
opportunities for occupational therapists, and while
they have traditionally worked within the health system, they are now finding themselves increasingly in
demand across a wide range of sectors.
Models of health and disability have also had an
influence on how health and disability are conceived
and funded and, subsequently, how services are
delivered. Disability was viewed traditionally as an
attribute of the person, which meant that services
were primarily focused on treating the person’s disease or disorder. More recently, the social model of
disability, which views disability as the inability of
society to accommodate the diverse abilities in the
community, has shifted the focus from addressing
the limitations of the individual to addressing barriers in the environment. Furthermore, antidiscrimination and civil rights legislation, which acknowledges
the rights of all people in the community, has led
to the development of policies that aim to provide
everyone equitable access to community facilities
and services. Consequently, revised building standards now ensure that people with disabilities can
access public buildings. A growing interest in the
design of residential buildings—to enable people
to function well in their home environments across
their life span—has also led to residential design
standards and legislation being developed.
DEMOGRAPHICS
Increased life expectancy, improved child mortality rates, falling fertility rates, and unprecedented
socioeconomic development over the last 50 years
have resulted in populations aging in almost all
countries of the world, with most people worldwide
expected to live beyond 60 years of age for the first
time in history (United Nations, 2015; World Health
Organization [WHO], 2015). Existing evidence shows
that older people contribute to society in many ways,
despite existing and misleading stereotypes of frailty
and dependence (WHO, 2015). The contribution of
older people is, however, significantly dependent
upon their health, and although poor health does
not need to dominate old age, disability is part of the
human condition. At some point, almost everyone
will experience temporary or permanent difficulties
in functioning, and those who live into old age are
at increasing risk of acquiring impairments (WHO,
2015). In 2004, it was estimated that over 1 billion
people in the world have a disability, approximately
15% of the world’s population. Between 110 and 190
million adults worldwide had significant difficulty in
daily functioning (WHO, 2011). Lower-income countries had a higher percentage of people with a disability than did higher-income countries; however,
in all countries, older people had higher rates of
disability (WHO, 2011).
Data from the U.S. Centers for Disease Control
and Prevention reported that in 2013, over 50 million
U.S. adults (22.2%) reported having a disability, with
mobility impairment being most frequently reported,
followed by cognitive impairment (Courtney-Long et
al., 2015). In the United Kingdom, there are 11.9 million
people with a disability, with 67% of people over the
age of 75 years reporting a long-standing illness or
disability (Papworth Trust, 2016). In Australia, 18.5%
of the population has reported having a disability
(over 4 million people), with 14.9% (3,412,500) of the
Australian population reporting a core activity limitation (limitation in self-care, mobility, and/or communication; Australian Bureau of Statistics [ABS], 2013).
Over half (50.7%) of people over age 65 years report
having one or more impairments (ABS, 2015).
The incidence of disability is growing worldwide
due to both an aging population and an increase
in chronic diseases. Population aging has emerged
as a key issue for governments globally as the proportion and number of older people in populations
around the world increase dramatically as a result
of increases in life expectancy and a steady decline
in fertility rates (WHO, 2015). In many developed
countries, the rise in the birth rate between 1946
and 1964 means that a large number of people are
in or approaching retirement. This “wave” of baby
boomers is expected to have an enduring impact
on Western societies for many decades to come
(Freedman, 2007).
In 1950, when baby boomers were first counted
in the U.S. Census, people aged 65 years and older
made up just 8% of the population. In 2010, people
aged 65 years and older were projected to represent
13% of the total U.S. population, and by 2030, this
figure is expected to reach 19% (Vincent & Velkoff,
Approaches to Service Delivery
19
Figure 2-1. Disability and aging. (Reprinted
with permission from Bernard Steinman, MS,
Research Assistant at the Fall Prevention Center
of Excellence, Andrus Gerontology Center USC.
Data Source.)
2010). Globally in 2015, people over age 60 years
made up 12% of the world’s population. This is projected to rise to 22% by 2050, resulting in significant
challenges to the economic, health, and social systems (WHO, 2015).
Although there is great diversity in function and
health in older individuals, aging is associated with
a general decline in physical function, an increased
vulnerability to environmental challenges, and a
growing risk of disease (WHO, 2015). Aging is frequently associated with loss of sensory function,
reduced mobility, declining immune function, and
some cognitive changes (WHO, 2015). Older people
are also likely to experience more than one chronic
condition at the same time (multimorbidity), as well
as health conditions that are usually only experienced in old age such as frailty, continence issues,
and high risk of falls (WHO, 2015). As a result, daily
functional ability and levels of activity may decline.
In the United States, for the population of people
65 years and older, 26% reported activity restrictions as a result of disability (Johnson & Wiener,
2006). Although the incidence of activity limitations
is not significantly rising for this population in the
United States, there is an increasing incidence of
activity limitation for people 55 to 64 years since
2000 (Freedman et al., 2013). Figure 2-1 displays the
growing rate of disability that occurs when people
age.
The capacity of people to engage in daily activities and remain living in the community as they age
or acquire a disability is not only influenced by individual physical and mental capacities, but also by
the quality and nature of their living environment,
including social, political, physical, and built environments (WHO, 2015). Relocation in old age is usually the result of a number of interacting aspects of
housing and health, including level of dependency in
daily activities and the usability or accessibility of the
home environment (Granbom, L fqvist, Horstmann,
Haak, & Iwarsson, 2014). In 2007, a survey of housing
in England identified that only 3.4% of homes had
features that made them “visitable” for people with
mobility problems, with particular problems associated with older-style housing (Communities & Local
Government, 2009). In Australia, many people live in
detached houses in the suburbs that are designed
for young families with private transport. These
dwellings have features that create hazards and barriers for occupants with disabilities or who are aging
(Bridge, Parsons, Quine, & Kendig, 2002; Faulkner
& Bennett, 2002). Existing housing that is targeted
for older people in Australia is also problematic as
it often fails to meet accessible design and livability
standards (Aged and Community Services Australia
[ACSA], 2015). Lack of housing accessibility has been
identified as a key indicator for relocating older people to special housing in European countries such as
Sweden (Granbom et al., 2014).
Housing is generally designed and constructed
with little thought to the access, safety, independence, and location needs of the residents, and the
need for accessible housing far exceeds supply in
most countries (Imrie & Hall, 2001; Liebermann,
2013). Most housing in the United States is inaccessible, and policy priorities in some states can impede
the production of accessible housing (Liebermann,
2013; Steinfeld, Levine, & Shea, 1998). Houses with
20
Chapter 2
stairs, narrow doorways and corridors, inaccessible
toilets and bathrooms, and limited space “create”
disability (Heywood, 2004a; Oldman & Beresford,
2000) and can compromise the safety (Stone, 1998;
Trickey, Maltais, Gosslein, & Robitaille, 1993), independence (Frain & Carr, 1996), and well-being
(Heywood, 2004a) of older residents and those with
disabilities. These design features are costly to modify (Tabbarah, Silverstein, & Seeman, 2000) and can
contribute to early institutionalization (Rojo-Perez,
Fernandez-Mayoralas, Pozo-Rivera, & Rojo-Abuin,
2001). Because activity limitations are likely to
increase as people age, it is not surprising that governments throughout the world are actively engaged
in social and health reforms to ensure the ongoing
health and well-being of older people and people
with disabilities living in aging and unaccommodating homes in the community.
LEGISLATIVE
AND
DEVELOPMENTS
AND
POLICY
DIRECTIONS
The emergence of the civil rights movement and
antidiscrimination legislation in the 1960s and 1970s
resulted in many governments committing to ensuring the acceptance and inclusion of people with
disabilities in society. More than 40 nations adopted
disability discrimination legislation during the 1990s
(WHO, 2011). Legislation such as the Americans
With Disabilities Act (1990), Australian Disability
Discrimination Act (1992), U.K. Equality Act (2010),
and the proposed European Accessibility Act all provide provision for the development of accessibility
standards for public buildings, recognizing the role
of the built environment in affording people access
to community facilities. In the residential sector, the
movement toward deinstitutionalization contributed
to the emphasis on also creating housing environments that could accommodate people with disabilities, as indicated in the United States by the Fair
Housing Amendments Act (1968) and in the United
Kingdom by the Lifetimes Home Standard (2010).
Deinstitutionalization shifted the focus from providing care in specialized settings to supporting people
in their own communities. These policy initiatives
have stimulated the development of other policies
and services dedicated to building and modifying
home environments to move people from congregate care to independent community living. In the
United States, the 1999 Olmstead Decision requires
that states provide services to older people and
people with disabilities in the “most integrated setting appropriate,” resulting in an increase in demand
for community-based services and housing (Pynoos,
Nishita, Cicero, & Caraviello, 2008, p. 85). The creation of the United Nations Convention on the Rights
of Persons with Disabilities (2006) and the ongoing implementation of disability discrimination or
antidiscrimination legislation continue to influence
policy relating to the provision of accessible housing
within various countries.
The concern around the world about the aging
population and its impact on health and social services has resulted in a number of policy initiatives
being proposed and implemented. In the United
States, the role of housing in supporting older people
in the community is gaining recognition from policymakers (Lipman, Lubell, & Salomon, 2012; Pynoos,
Liebig, Alley, & Nishita, 2004). Older Americans have
been exerting political pressure through organizations such as the American Association of Retired
Persons and are increasingly recognized as having
significant voting power (National Institute on Aging,
2006). These demographic, social, and policy changes have stimulated a rapid expansion in industries
providing services for older people, including health
care, aged care, financial services, and housing.
These service industries have also become increasingly vocal, organized, and politically influential
(Jones, de Jonge, & Phillips, 2008).
Although policy has concentrated on the need for
more inclusively designed residential environment,
for the most part, the U.S. regulations have applied
to multi-unit developments, omitting the vast array
of single-family and smaller complexes where older
people live. In the United States, there have been
attempts to rectify this problem by concentrating on
designing existing units and building housing to suit
a diversity of users, including older people and people with disabilities in the first instance. The Eleanor
Smith Inclusive Home Design legislation has been
created to ensure new homes are built with visitable
features (to allow someone to visit the home using
the no-step entry, sit in the living room, and access
the toilet in the bathroom) but has yet to be passed
by the U.S. Senate.
There are ongoing efforts to make accessible,
adaptable, and universal design part of new home
design construction through groups lobbying the
government’s national construction codes (e.g.,
Australian Network of Universal Housing Design)
and trying to institute voluntary programs with
the building sector (e.g., Better Living Design in the
United States [http://betterlivingdesign.org/], Livable
Housing Australia [http://www.livablehousingaustralia.org.au/], Lifemark Homes in New Zealand [http://
www.lifemark.co.nz/home.aspx], and Lifetime Homes
in the United Kingdom [http://www.lifetimehomes.
Approaches to Service Delivery
org.uk/]. Although there has been a lack of take-up in
the new construction arena of the design guidelines
created by these organizations, the guidelines are
being used by occupational therapists as a major
reference when recommending home modifications
to residential dwellings.
However, the reliance on new building development to meet the needs of older people or people
with a disability is tenuous, considering it is widely
acknowledged that “development, design and building processes are inattentive to the needs of disabled people” (Imrie & Hall, 2001, p. 3).
Of the more than 60 countries that have accessibility legislation worldwide, very few of these
consider accessibility to new private residences
part of the legislative framework. Even in countries
where the concept of “visitability” (basic accessibility features in newly constructed residential
homes) is legislated, provisions have been “beset
by problems of vagueness and ambiguity and rarely
used to their full potential” (Imrie, 2006, p. 15), and
it is acknowledged that there is a “long way to go in
increasing the number of homes that are accessible
and supportive” (Nishita, Liebig, Pynoos, Perelman,
& Spegal, 2007, p. 13).
Given this situation, there is a clear role for
modification of existing housing as a strategy to support community living for older people and people
with a disability. In the United Kingdom, a housing
condition survey found that only minor works were
needed to increase the number of existing accessible houses from 110,000 to 920,000 (Communities
& Local Government, 2009). However, in many
developed countries, home modification services,
although on the increase, continue to lack appropriate recognition at a legislative and policy level
(Jones et al., 2008). Home modifications are starting
to be considered in policy development as they can
make a general contribution to the implementation
of aging policy and, more specifically, to health, community care, and housing policy for older people.
Home modifications can reduce the need for
hospitalization of older people and the demand
for expensive in-home and residential aged-care
services (Kim, Ahn, Steinhoff, & Lee, 2014; Mann,
Ottenbacher, Fraas, Tomita, & Granger, 1999). Home
modification can also play an important role in preventive health by reducing the incidence of accidents
and falls among older people, reducing the costs
associated with home injuries, and reducing the
mental and physical strain on caregivers (Heywood,
2005; Keall et al., 2015, Newman, 2003). Modifying
the homes of older people can also reduce expenditure on social housing because it constitutes a less
21
expensive form of housing assistance than direct
social housing provision (Jones et al., 2008). Home
modifications can also help caregivers who form the
backbone of personal care assistance for disabled
people of all ages. There is even some preliminary
evidence that home modifications, in conjunction
with occupational and physical therapy, can reduce
mortality (Gitlin, 2003).
In terms of promoting positive aging, home modification provides a means of facilitating healthy and
independent living and allowing older people to continue to participate actively in home and community
life. Appropriate housing is fundamental to an individual’s well-being and social participation (Jones et
al., 2008), and modifications can play an important
role in enabling people to live independently and
safely, to actively participate in household activities,
and to maintain involvement with family and friends
(Aplin, de Jonge, & Gustafsson, 2015). When people
choose to remain living in their own home for as long
as possible, modifications, along with other community care services, can enable them to age in place.
If people choose to relocate, they will have access
to more suitable housing and locations, where the
homes might be designed or adapted to better suit
their requirements.
The establishment, design, and delivery of a home
modification service varies between countries and,
like accessibility in the built environment, is influenced by the type, nature, and direction of legislation and policy in existence in a particular country.
Legislation and flow on policy directly affect the way
home modification services are resourced, including
the amount of funding available, eligibility criteria,
and the type and level of modification that is provided (Jones et al., 2008). In many non-Western or
developing countries, minimal legislative and policy
frameworks are in place and there is minimal welfare
support for people with a disability. This lack of legislative support results in few resources or limited
infrastructure to support modification of home environments for older people or people with a disability
(Imrie, 2006).
Though many developed countries have legislation and policy in place that support full participation and equity for people with disabilities and
aging in place for older people, the outworking of
these principles is complex, and there is often no
overarching framework that legislates the provision
of home modification services (ACSA, 2015). In countries such as the United States, New Zealand, and
Australia, disability issues are considered within a
human rights legislative framework rather than a
rehabilitative or health framework as in Sweden.
22
Chapter 2
Sweden provides a clear example of how legislative and policy frameworks support consistent and
comprehensive home modification service development. Sweden’s legislation in relation to older people
and people with a disability establishes a framework
for the development of support services, including
provision of personal care and home modification
services (Anderberg, 2009; Lilja, Mansson, Jahlenius,
& Sacco-Peterson, 2003). The Home Modification
Law (1992) in Sweden mandates that local authorities
provide grants for housing modification services to
anyone who has a disability, irrespective of financial
or housing situation (Anderberg, 2009; Petersson,
Lilja, Hammel, & Kottorp, 2008). Policy arising from
the legislation ensures that people with a disability
do not bear the cost of reducing environmental barriers to their activities of daily living. Under this
legislative framework, home modifications are considered essential elements of health care, and consistent provision of home modifications is supported
through policy and practice frameworks (Petersson
et al., 2008).
As outlined in Chapter 4, human rights legislation, such as the Americans With Disability Act
(1990) and the Fair Housing Amendments Act (1968;
housing-specific amendments to the Civil Rights
Act of 1968; U.S. Department of Housing and Urban
Development, 2007), enshrines the right of people
with a disability to equitable and nondiscriminatory
access to housing and housing services. However,
supporting a person with care needs to live in the
community very often requires a diverse array of
services, including home help, home maintenance,
personal care and assistance, assistive technology,
and home modifications. Many of these services vie
for the same funding, and home modification service
does not always receive distinctive treatment (Lilja
et al., 2003; Pynoos, Nishita, & Perelman, 2003).
In many countries such as the United States, the
United Kingdom, and Australia, there is a historic
fragmentation of housing, health, and community
care in policy areas, with the result that there is a
lack of coordinated policy development and consequent service provision to support communitybased living (Faulkner & Bennett, 2002; Heywood &
Turner, 2007). This lack of specific acknowledgment
of home modification services within policy and
the associated poor integration of related areas at
a policy level significantly affect the development
and funding of home modification services, with
public funding for home modification services being
limited. In the United States and Australia, home
modification service delivery has been frequently
described as being less than ideal, with lack of sufficient funding, poor coordination of services, and
lack of geographic coverage of services cited as
some of the main barriers to effective service delivery (ACSA, 2015; Duncan, 1998a; Jones et al., 2008;
Pynoos, 2001; Sorensen, 2012; Tabbarah et al., 2000).
Funding and Home Modification
Services
As indicated previously, funding arrangements
for home modification services are directly linked
to provisions within the legislation of a particular
country. Both Sweden and the United Kingdom have
legislation that ensures a specific allocation of funds
for home modification services. Within the United
Kingdom, the mandatory Disabled Facilities Grant
requires local authorities to fund a range of modifications to the homes of eligible people with a disability. However, even within countries that legislate
for funding for home modifications, problems exist.
Within the United Kingdom, the Disabled Facilities
Grant is criticized as being poorly publicized, and
the grant is distributed in a reactive rather than
proactive way, resulting in poor uptake and lessthan-effective administration and outcomes (Awang,
2002; Heywood, 2005). Unlike Sweden, where funds
are available irrespective of individual financial circumstance, in the United Kingdom, funding is limited
to people on pensions and with low incomes, and
there are differing levels of service across different
geographical areas. In both the United Kingdom and
Sweden, concerns exist as to the impact of an aging
population on the viability of the current schemes,
with an increasing gap existing between need and
available resources.
In contrast, although funding is available for
home modifications in both the United States and
Australia, it is not mandated by legislation and is
generally considered to be difficult to access and
insufficient to meet existing needs (ACSA, 2015;
Smith, Rayer, & Smith, 2008). Both countries have
described the organization and provision of home
modification services as a complex “patchwork” of
programs (ACSA, 2015; Jones et al., 2008; Pynoos,
2001). Programs are often funded from a variety of
diverse sources (federal, state, local, and community), resulting in fragmentation, inflexibility, and
administrative burden, and there is an absence of
integrated information systems about home modification services (Jones et al., 2008; Smith et al.,
2008; Sorensen, 2012). Without a legislative mandate
for funding, the cost of home modifications is often
borne by the individual (The Scan Foundation, 2010).
In both the United States and Australia, even federally funded programs differ from state to state with
regard to requirements and resources available,
Approaches to Service Delivery
and funding is often in a block grant with a range
of other essential services related to community
care vying for priority (Duncan, 1998b; Jones et
al., 2008; Sorensen, 2012). In many countries, such
as Australia, the United Kingdom, and the United
States, there has been a call to reconsider the current
approach to the organization and provision of home
modification services. There is a clearly identified
need to establish specific policy goals and benchmarks for service delivery to address the great disparity that exists in levels of service provision within
various countries (ACSA, 2015; Duncan, 1998b; Jones
et al., 2008; Pynoos & Nishita, 2003; Sorensen, 2012).
SERVICE DELIVERY SYSTEMS
As identified previously, home modification services in many countries have not developed as
a planned and cohesive strategy. Various types
of services have been developed and delivered
through different service systems, each with their
own particular goals, approaches, and interventions.
This is largely because modification services in
many developed countries have been developed and
funded through a variety of programs and provided
through an assortment of services with various
aims. Occupational therapists generally work across
different programs in an effort to stitch together a
suitable modification solution for each client. It is
often difficult for both therapists and their clients
to comprehend the range of services available and
what each can offer any given individual. Much of
this complexity of home modification services is a
result of being at the intersection of health, community care, and housing services and policies. Each of
these has a different perspective on the goal of home
modifications and tends to shape home modification practice through different policies and funding
regimes. As a consequence, the roles of stakeholders
involved in home modification practice also vary.
Although the role, level, and nature of involvement
of each key stakeholder differ between perspectives,
there is a general consistency in the type of people
(stakeholders) who are usually involved in the delivery of a home modification service (Pynoos, Sanford,
& Rosenfelt, 2002). The key people involved in the
delivery of home modifications commonly include
the person (home dweller) and his or her significant
others (this can be family, friends, or caregivers); the
referring agency; the organization managing and/or
providing funding for the service; construction and
building professionals; design professionals; and
the health professional, most often an occupational
therapist.
23
Commonly, home modification programs use a
combination of employed staff (such as a program
coordinator and employed tradesmen/handymen
to carry out minor work) and subcontractors, who
are usually licensed professionals (including occupational therapists) operating under contract. The
challenge for occupational therapists is to operate
effectively within and across programs to develop
an approach to home modifications that transcends
one particular program. In order to appreciate the
impact of the service context on practice and to
develop a holistic approach to home modification,
each of these service environments needs to be
examined.
HEALTH PERSPECTIVE
Home modifications and home adaptations are
widely defined in health care contexts as “any permanent alteration to a building carried out with the
intention of making [it] more suitable for a disabled
person” (Heywood, 2004a, p. 134). In this context,
changes are made to the home environment “in
order to accommodate a particular set of human
abilities” (Bridge, 2005, p. 2). Like many interventions within health and rehabilitation settings, home
modifications are viewed as a means of addressing
or correcting problems specific to an individual
(Wylde, 1998). Home modifications are provided as
part of discharge planning following hospitalization
(Auriemma, Faust, Sibrian, & Jimenez, 1999; Lannin,
Clemson, & McCluskey, 2011) or within a community
health or health-funded in-home service.
Within a health context, home modifications are
generally recommended by professionals to ensure
that an individual with a particular impairment or
health condition is safe and independent in his or
her home (Auriemma et al., 1999) or to decrease the
likelihood of admission to a hospital or care facility (Auriemma et al., 1999; Gitlin, Miller, & Boyce,
1999). Health conditions, which are generally viewed
as having a standard presentation and predictable
pathology, are managed using practice guidelines
or protocols of care. This can result in recommendations focusing on a specific health problem, with
less consideration being given to other difficulties,
impairments, or aspirations the person might have
(Tinker et al., 2004). The primary focus of interventions within the health context is often on remediation or correction of the health condition, with
medications and interventions that remediate the
condition taking precedence over other interventions. Home modifications, assistive devices, and an
array of other interventions that promote the safety
24
Chapter 2
and independence of people with chronic conditions
or long-term disabilities are frequently less of a priority within the health system. This factor is often
reflected in the priority these services are given,
along with the budget allocated for them.
Focus of the Health Perspective
Within a health perspective, the home environment is typically conceptualized as a discrete physical entity where modifications can be routinely
recommended to accommodate specific functional
impairments or health-related limitations. Although
pre-discharge home visits are acknowledged as
important in preventing readmission to hospital,
increasing trends toward early discharge have
contributed to reduced discharge preparation and
decreased numbers of home visits within some
health services (Lannin et al., 2011). Frequently, an
individual’s functional ability is assessed in a clinical
setting, and recommendations for modifications to
the home environment can be made without undertaking an on-site visit (Lannin et al., 2011; Pynoos,
Tabbarah, Angelelli, & Demiere, 1998). When a home
visit is undertaken, the focus is often on potential
safety hazards or physical barriers to performing
self-care activities. Consequently, the inside of the
home—in particular, the bathroom and bedroom,
as well as an access point in and out of the home—
receives most attention. Typically, modification recommendations in health-based services tend toward
nonstructural changes, such as grab rails, shower
seats, and other assistive devices (Pynoos et al.,
1998; Renforth, Yapa, & Forster, 2004). Although
funding programs for major modifications involving structural changes such as widening doorways,
modifying bathrooms, and installing ramps, do exist
in many developed countries, such modifications
are less common because of the design and construction time involved, the financial cost, and the
expertise and resources required in attaining these
modifications (Auriemma et al., 1999; Pynoos et al.,
1998; Tabbarah et al., 2000). Moreover, because of
regulatory and budget constraints, there is often
little follow-up to ensure that modifications are working effectively (e.g., there might be a problem with
faulty equipment or poor installation, or the resident
or caregiver might need training in how to use them).
With health-based services focused on ensuring that people with health conditions, injuries, or
impairments are able to return home from the hospital and be safe and independent when performing
self-care tasks in their home, practice and client outcomes are constrained in a number of ways. When
function is defined in terms of impairments resulting
from a specific injury or health condition, care protocols are developed for each of these. Consequently,
the unique needs of the individual are often not well
addressed. When people have similar injuries or conditions, the functional limitations—and the impact
of these—can vary from one person to another.
This generally necessitates a targeted assessment
of each individual to assess his or her abilities and
the performance of various activities. Furthermore,
the particular priorities and preferences of individuals, their personal resources, and the strategies
they use to address activity restrictions combine
to influence the nature of difficulties identified and
how these might be best addressed. With a focus on
individual function, less attention is likely to fall on
the environment—the challenges it presents when
undertaking various activities or how it might be
modified to promote further activity engagement. In
addition, if performance is evaluated in the hospital
environment, this does not acknowledge the interaction between the individual, his or her activities, and
the home environment. Consequently, the ability of a
person to function on returning home can be either
under- or overestimated because the familiarity of,
or challenges within, the home environment have
not been recognized.
Recent concerns about the prevalence of falls
among older people living in the community and the
resultant costs to the health system have directed
attention to addressing hazards in the home environment. With approximately half of falls occurring
inside the home (Rogers, Rogers, Takeshima, &
Mohammod, 2004), home modifications have been
identified as one of a number of risk-management
strategies to reduce the number of falls among
the elderly (Gillespie, Gillespie, Cumming, Lamb, &
Rower, 2001; Keall et al., 2015; Petersson et al., 2008).
A number of potential environmental hazards have
been identified, including clutter, obstacles, loose
rugs, lack of supports, and poor lighting (Clemson,
Roland, & Cumming, 1997; Keall, Baker, HowdenChapman, & Cunningham, 2008), and interventions
are focused on removing these to promote safety.
Falls risk and hazard identification have provided the
foundation for many health-funded initiatives, and
there is some evidence that broadly targeted programs aimed at removing environmental hazards in
the homes of older people in the community reduce
the incidence of falls (Keall et al., 2015). Success has
been achieved with tailored programs targeted at
the specific needs of people with increased falls risk,
such as the frail elderly (Cumming et al., 1999) and
those who have fallen previously (Close et al., 1999;
Nikolaus & Bach, 2003). This suggests that the individualized and holistic approach to environmental
Approaches to Service Delivery
interventions favored by occupational therapists
is likely to be more effective in reducing falls than
those focused on hazard reduction alone (Gillespie
et al., 2012). A meta-analysis of fall prevention interventions also indicates that multifactorial interventions including medical risk assessment and management, physical activity, and home assessment
and modification are likely to produce the largest
reduction in falls among those at moderate to high
risk (Gillespie et al., 2012; Rubenstein & Josephson,
2006). In this scenario, occupational therapists play
a role as members of an interdisciplinary team.
Regardless, as a profession, occupational therapists
need to provide more evidence of the efficacy of
their unique approach if their services expect to
benefit from the funding being made available to
reduce the incidence of falls among the elderly.
Traditionally, home modification services within
health systems have largely focused on physical
impairments. This has resulted in well-developed
assessments, designs, resources, and services aimed
at addressing physical impairments. Somewhat less
attention has been given to addressing the sensory,
cognitive, emotional, and social changes associated with aging. With the high prevalence of vision
and hearing impairment among older people, there
is a growing interest in making the home environment more manageable and safe for those with
sensory impairments (e.g., using modifications such
as enlarged fittings, enhanced lighting, amplification
devices, auditory signals, and contrasting colors;
Auriemma et al., 1999; Rooney et al., 2016). Although
it is important to address existing impairments
through environmental interventions, further attention also needs to be directed to creating emotionally and socially supportive home environments
that make it easier to carry out daily activities in
the home. This would help to promote older people’s self-confidence and self-esteem (Pynoos et al.,
1998), and it would ensure that they maximize their
engagement in daily activities, thus optimizing their
general health and well-being. As a result of our less
well-developed understanding of sensory, cognitive, emotional, and social issues in the home and
associated environmental interventions, there are
fewer assessments, designs, resources, and services
dedicated to addressing these concerns within the
health arena. Consequently, therapists can struggle
to adequately address these needs with their clients,
who, as a result, continue to struggle to manage in
their home environment.
With the aging population and the rising incidence of dementia (Plassman et al., 2007), there
is a growing interest in supporting older people
with cognitive changes to remain living safely and
25
independently in the community (Giovannetti et
al., 2007; Struckmeyer & Pickens, 2015). The focus
of health interventions is also to assist the caregivers, who are often responsible for supervising and
assisting people in daily activities and managing
those who are difficult or dangerous (Colombo,
Vitali, Molla, Gioia, & Milani, 1998; Gitlin & Corcoran,
2000; Silverstein & Hyde, 1997). Home modifications
might include nonstructural changes, such as reassigning rooms, installing fencing and gates, fitting
safety locks on doors and cupboards, adding outlet
covers and night lights, and improving lighting. A
range of electronic devices has also been used, such
as smoke detectors and movement monitoring and
alarm systems (Silverstein, Hyde, & Ohta, 1993).
Occasionally, structural changes such as an additional bathroom or bedroom are undertaken.
Key Stakeholder Roles and Perspectives
Within the health perspective, the role of the
occupational therapist and associated outcomes
for clients can be constrained through the health
service/organization’s policies and funding systems.
The role of the occupational therapist within home
modification service delivery has been promoted as
one of understanding and meeting the individual’s
goals so that the individual is enabled, enhanced, and
empowered to make choices, solve problems, and
maintain control (Pickering & Pain, 2003; Pynoos et
al., 2003). However, the immediate focus on discharging the person from the hospital into a safe environment can mean that the long-term suitability of the
home environment is not adequately addressed
(Lannin et al., 2011). Minimizing safety concerns and
maximizing independence in self-care activities can
often divert therapists’ attention from determining
the real extent of risk and maximizing engagement
in meaningful occupations in the home. A focus on
mobility and access into and within the home can
result in inadequate attention being paid to access to
the yard, neighborhood, and community. In addition,
issues of personal concern, such as security, managing the ongoing maintenance of the home and garden
(Jones et al., 2008), the social acceptability of the
modifications, or the impact of the modifications on
the meaning or value of the home (Heywood, 2004b),
tend to not be acknowledged or are undervalued.
Within the health perspective, the home dweller
may be in the role of “patient” and as such is seen
as a passive recipient of services rather than as an
active participant in decision making. Inclusion of
the home dweller and significant others in decision
making about changes to the physical environment
is of paramount importance. The issue of participation and control over the modification process is
26
Chapter 2
one that has been identified as a key area in the
literature (Heywood, 2004b, 2005; Johansson, Borell,
& Lilja, 2009; Pickering & Pain, 2003; Tanner, Tilse, &
de Jonge, 2008). Poor outcomes in home modification services have been identified as being related
to poor understanding of the individual’s need and
limiting assessment to a functional understanding
of the person without consideration of issues of control, participation, or the needs of significant others
(Heywood, 2004b).
It is essential that the occupational therapist be
committed to a participatory decision-making process. The occupational therapist needs to ensure
that the home dweller is actively engaged in the
decision making around the intervention planned.
Communication needs to be clear and choices
around options provided (Heywood, 2004b). This
approach will help reinforce the meaning of home
as a primary territory with a perceived degree of
personal control (Smith, 1994; Tanner et al., 2008).
If the person is accustomed to a passive role
with health care or other professionals, the home
dweller may not feel confident to voice his or her
opinion or to take an active role in decision making.
The occupational therapist needs to be sensitive to
this dynamic and support the person to give his or
her views and opinions, not only in his or her own
interactions but in interactions between the person
and other stakeholders, including other health professionals, discharge planners, and building professionals. Because the occupational therapist is the
person who gathers assessment information about
the individual, he or she is often well placed to negotiate better outcomes for an individual.
In summary, health care systems, policies, and
programs are key contextual elements in developing
and providing home modification services. Within
this context, modifications largely have been associated with discharge planning following hospitalization, with care of people with disabilities or chronic
health conditions in the home environment (including the older people with dementia and their caregivers), and with fall prevention. Though practices
vary widely from one service to another, there are
a number of prevailing characteristics of the health
approach to home modifications. The primary focus
is often on a particular health problem or condition,
with home modification perceived as one of a suite
of interventions designed to remediate the problem
or address dysfunction. Key concerns center on
safety and the capacity to independently perform
self-care activities. Environmental interventions are
generally minor, nonstructural modifications, and
structural changes are used infrequently. With a
focus on individual function, health-based services
are less concerned with the long-term suitability of a
residence; the social acceptability of modifications;
and issues of identity, meaning, and lifestyle. The
occupational therapist’s role may involve promoting
the home dweller as an active rather than passive
participant in decision making, ensuring optimal
home modification outcomes for the individual and
their significant others. Although there is a growing
appreciation of sensory, cognitive, emotional, and
social issues and associated environmental interventions, assessments, designs, resources, and services aimed at addressing physical impairments are
more highly developed. New technologies present
increasing opportunities to assist, as well as manage
and monitor, people in their homes; however, these
need to be used judiciously to ensure they do not
encroach on the rights and autonomy of the householder.
COMMUNITY CARE PERSPECTIVE
In recent decades, home modifications have
emerged as one of a range of services provided by
community care agencies. Others include home
nursing, delivered meals, home help, transport,
shopping assistance, allied health services, and
respite care. Community care services are designed
to directly assist older people and people with
disabilities to remain living in their own homes
and communities, as well as support their families
and caregivers in providing care (Steinfeld & Shea,
1993) and reduce admissions to residential care
(Duncan, 1998a; Stone, 1998). Modifications and
associated services are seen as being essential in
delaying reliance on personal assistance and avoiding an unwanted move (Gitlin et al., 1999). Within
this service environment, home modifications have
been defined as “adaptations to living environments
intended to increase ease of use, safety, security and
independence” (Pynoos et al., 1998, p. 3). Although
the main focus of health contexts is on home modifications to ensure safety and independence, the community care sector also provides maintenance and
security services, acknowledging that older people
and people with disabilities also need to maintain
the dwelling and be safe and secure in their homes
in addition to managing activities in and around the
home. The way in which these services are delivered
varies considerably from one location to another.
However, modification assessments are generally
undertaken by professionals working in either health
or social services (Klein, Rosage, & Shaw, 1999),
whereas maintenance and security assessments
can be undertaken by a wide variety of individuals,
Approaches to Service Delivery
including handymen, tradespeople, building contractors, social service organizations, and families
themselves (Pynoos et al., 1998). Although the modification work is primarily contracted out to builders
and other tradespeople, some service providers
employ their own trade staff. Some of these providers might be familiar with making modifications;
however, many are untrained, thereby requiring
specific instructions from the occupational therapist
regarding what and where to install them.
A range of strategies is used in the community
care context to enable people to remain living in
their own homes. These strategies have been classified as being additive, subtractive, transformative, and behavioral (Pynoos, Steinman, Nguyen,
& Bressette, 2012; Steinman, Nguyen, & Do, 2011).
Additive modifications are those in which supports
and structures are added to the home environment. These can be major changes such as ramps,
lifts, and stepless showers or minor ones such as
additional lighting, grab rails, or special equipment
or assistive devices. Subtractive modifications are
where items are removed from the environment to
improve safety, such as the removal of clutter or
hazards. Transformative modifications change or
reconfigure existing structures and spaces in the
home such as the reorganization of kitchen utensils
and rearranging lounge furniture to improve access,
as well as structural changes such as widening existing doorways or lowering countertops. Behavioral
adjustments alter the way in which activities are
carried out in the home environment such as using
a shower recess instead of a plunge bath to improve
safety (Pynoos et al., 1998).
In the United Kingdom, housing modifications or
adaptations are classified as an assistive technology, defined as “any device or system that allows
an individual to perform a task that they would
otherwise be unable to do, or increases the ease
and safety with which the task can be performed”
(Cowan & Turner-Smith, 1999, p. 235). However,
assistive devices are typically mobile and are not
attached to the structure of the house (Pynoos et
al., 1998), whereas home modifications are generally permanent, secure, and fixed in place. Assistive
devices are sometimes preferred by clients and professionals, especially when they are uncertain about
how to undertake structural changes (Pynoos et al.,
1998; Steinfeld et al., 1998), when they are reluctant
to commit to a permanent or costly modification
(Pynoos & Nishita, 2003), or if they are renting and
are uneasy about making changes to which a landlord might object or require them to remove if they
leave.
27
Focus of the Community Care
Perspective
In community care, the focus shifts from the
specific performance limitations of the person to an
analysis of the fit between the person and his or her
home environment. Lawton and Nahemow (1973)
were the first to recognize the challenges, or “press,”
provided by the environment and proposed that
these were unique for each individual. Subsequently,
practice models developed over the past decade
have highlighted the limitations of focusing on either
the person or his or her impairments or on the barriers in the environment, promoting the value of
examining the interaction between the person and
the environment (Rousseau, Potvin, Dutil, & Falta,
2001). The use of these models in the community
sector also encouraged a shift from assessing narrowly defined self-care activities to examining an
individual’s capacity to manage in the home and
the community (Peace & Holland, 2001). The focus
is on establishing balance between environmental
demands and individual competencies and adapting
the home environment to match the capabilities of
the person (Gosselin, Robitaille, Trickey, & Maltais,
1993; Rousseau, Potvin, Dutil, & Falta, 2002). In this
approach, difficulties experienced by the person in
the home are observed and analyzed, and identified
environmental challenges are then addressed using
environmental interventions tailored to meet the
particular needs of the individual.
The role of the environment in supporting competence or creating incapacity is also reflected in the
way in which the global view of disability has altered
in recent decades. Rather than simply viewing disability as a problem with an individual, disability is
now seen as “a dynamic interaction between health
conditions and contextual factors, both personal
and environmental” (WHO, 2011, p. 4). This “biopsychosocial model” of disability is presented as a
“workable compromise” between medical models
that focus on the person as disabled and social models that focus on society as the cause of disability
(WHO, 2011, p. 4).
Problems in the home result from an inability of
the home environment to accommodate the changing capacities of the person (Cowan & Turner-Smith,
1999; Tinker et al., 2004). Older people have been
described as being “architecturally disabled” by
inadequate design (Hanson, 2001), leading to an
emphasis on reducing environmental barriers in the
homes of older people and in residential design generally. However, the biopsychosocial model of disability does not restrict its view to purely physical
aspects of the individual’s immediate environment.
28
Chapter 2
It also acknowledges the impact of society on an
individual’s capacity to engage in activities identifying “support, relationships, attitudes, services,
systems and policies” as environmental factors that
can facilitate or hinder an individual’s participation
(WHO, 2011, p. 5).
Independence is a central concept in community
care, both generally and with respect to home modification services (Clapham, 2005). It is commonly
understood in this context to mean that the person
is able to live at home rather than in residential
care. Occupational therapists generally conceive
independence to be the ability to perform a task
without assistance; therefore, they seek to provide
training or a device or to modify the environment
in order to remove the person’s reliance on others.
However, for many people, independence holds a
more nuanced association, including “being able to
look after oneself,” “not being indebted to anyone,”
and “the capacity for self-direction” (Clough, Leamy,
Miller, & Bright, 2004, pp. 119-120). Independence
reflects a “sense of being in control with respect to
family, friends and formal caregivers” (Heywood,
Oldman, & Means, 2002, pp. 55-57). It is possible,
then, that some people might consider their independence enhanced by the assistance of others, a
home modification, or a move to residential care
where they have ready access to caregiving, providing they retain control of when and how assistance is
provided. In reality, this paradigm acknowledges the
interdependence of people.
Place of Home Modification
Services in Community Care
Although home modification services have been
established within community care systems in many
countries, these services tend to be underdeveloped
relative to other community care services as a result
of limited funding and scarcity of trained providers (Pynoos et al., 1998). Because community care
systems tend to prioritize those at risk of being institutionalized, services are prioritized and directed
toward those defined by the service as having the
fewest resources and the greatest level of need
(Clapham, 2005). Consequently, health and safety
concerns take precedence over independence and
quality-of-life issues (Mann, Hurren, Tomita, Bengali,
& Steinfeld, 1994), leaving home modification services fighting for resources in a system that provides
so many essential and costly support services.
Although modifications are seen as part of the
range of interventions with the potential to ensure
safety and independence and assist people to remain
in their homes and community, in reality, it is less
developed than the other services in the community
care sector where providers are more familiar with
the use of formal supports. The use of modifications
is also hampered by a lack of understanding of the
benefits of environmental interventions, restricted
access to services and personnel with appropriate
expertise, and the limited budgets available for such
interventions (Sorenson, 2012). Balancing priorities
and funding across maintenance, security, and modification services is also problematic when these
services are competing for their share of inadequate
budgets.
Key Stakeholder Roles and Perspectives
Within the community care sector, a key stakeholder is the administrating or funding organization that is often responsible for the coordination
of a range of community services, including home
modifications. Many organizations that administer
home modification services are by nature bureaucracies; that is, organizations based on rationalism,
hierarchy, and impersonal rules. Such organizations
tend to have a centralized system of policy and procedures that reflect a response to a “typical,” situation, and this approach to meeting individual need
can result in negative outcomes (Crozier, 1964, cited
in Dovey, 1985, p. 56; Heywood, 2004a; Sakellariou,
2015; Tanner et al., 2008). As well as being limited in
their response to individual need, the bureaucratic
organization model is nonparticipatory by nature,
with little scope for service users or recipients to
shape or determine service delivery (Awang, 2002).
The majority of service organizations have policies and practices regarding eligibility criteria,
which also define the population they are able to
serve and the limit of their service. For example, an
organization may decide to use allocated funds for
minor modifications only and in this way provide
service to a larger number of people than if they did
major, more costly modifications. This, however, will
place limits on the amount and type of modification
that can be recommended.
For the home dweller or householder, dealing
with a bureaucratic organization can be overwhelming, often due to the complexity of forms, people,
and processes that need to be negotiated to get
an outcome (Awang, 2002). The “typical situation”
approach of bureaucracies also means that, in the
application of rules and regulations, the individual
becomes invisible and may not be granted power to
influence outcomes (Sakellariou, 2015). There is an
inherent tension between the bureaucratic organization delivering the home modification service and
the service recipient around the issues of power and
control. Culturally, a bureaucracy is service-oriented
Approaches to Service Delivery
and inflexible, with little scope to allow users or
recipients of the service control or power in decision
making (Awang, 2002). These negative experiences
of organizational service delivery can undermine
the experience of home for the person and be profoundly disempowering for him or her, resulting
in negative health effects (Dovey, 1985; Heywood,
2004a; Sakellariou, 2015).
Coordinating the variety of services and service
providers required for the successful implementation of home modifications remains a prevailing issue
(Pynoos, 2004; Steinfeld et al., 1998). Modification
services require health and social service providers
to work with tradespeople, which can be complex
given the differences in roles, knowledge, language,
expertise, and expectations. Miscommunication and
mistrust prevail if the various stakeholders are not
afforded an opportunity to share knowledge and
develop an understanding of each other’s roles, language, expertise, and expectations. Community care
services, which have invested in the development
of trained home modification personnel, knowledge,
and resources, are well placed to achieve good client
outcomes. Services that require health and social
service providers to contract out modifications to
the private building sector are likely to experience
difficulties in delivering high-quality services and
outcomes. This is because of the difficulties in locating contractors with the necessary expertise, communicating requirements, and overseeing the work
being undertaken.
In the community care sector, occupational therapists have access to a range of services and interventions to assist their clients to remain in their homes
and communities. However, the ease with which
these resources can be accessed depends largely on
the structure of the funding and service system. The
development of modification services over the past
decade has resulted in a growing body of knowledge
and an increasing number of designs and products
being available. Recognition of the role of the environment in “disabling” people has resulted in the
development of occupational therapy models and
practice approaches that address the complexity of
the interaction between the person, activities, and
environment. Occupational therapists are unique
in their understanding of the activity engagement
and the role of the environment and stand out
among other health professionals in their capacity
to provide home modification services. An understanding of environmental fit allows therapists to
move from addressing problems to creating enabling
homes and communities that recognize the uniqueness of each person and his or her environment.
However, restricted funding and service policies
29
often constrain practice in addressing essential
issues and make it difficult for therapists to promote
activity engagement within the home and community. For example, often the priority in hospital discharge is getting a person out as quickly as possible.
As pointed out earlier, even though an occupational
therapist assessment and home modification might
be essential, these often do not occur, if at all, until
the person is already back in his or her home, struggling with both his or her own limitations and that of
the environment.
It is important that, wherever possible, the organization’s restrictions and limitations do not, in turn,
compromise the assessment process for the occupational therapist (Heywood, 2004a). The occupational
therapy assessment should reflect as much as possible a full understanding of the needs of the home
dweller rather than being restricted to what the organization will or will not fund or what organizational
processes typically promote. Because of their focus
on the individual, therapists are well placed to speak
up for the individual and promote a full understanding of his or her needs within the organizational
framework. If necessary, the occupational therapist
should push the boundaries of bureaucratic administration if it is important to address the needs of the
individual. It is also important that the home dweller
be fully aware of the options that are available to him
or her and be informed of ways his or her needs can
be met through other systems or services.
Use of Technologies
Increasingly, the potential of a range of new technologies is being recognized to help older people
and people with disabilities to live safely in their
homes and to assist in monitoring and managing
people with complex health conditions in the community (Colombo et al., 1998). Mainstream technologies such as mobile phones, sensors, passive alarms,
and security cameras are being used to enhance the
safety and independence of older people (Tinker,
1999), and dedicated environmental controls, robotics, and communication and security technologies
are being developed and integrated into the design
of “smart homes” (Cowan & Turner-Smith, 1999;
Tinker et al., 2004). Increasingly, smart technologies
are being used to help people remain living safely
and independently in their own homes. Smart technologies have the potential to decrease adverse incidents in the home and to allow health conditions to
be managed at home rather than in a health setting.
These technologies support people in their home
environment, and the potential to save overall health
care costs makes them attractive to those who fund
services.
30
Chapter 2
Security and home automation systems such as
security cameras, automatic door openers, keyless
entry, remote window and curtain opening, automated lighting sensors, etc. afford older people and people with disabilities safety and security and provide
them with a means to manage services, devices, and
appliances within the home environment. People
can regulate the temperature, lighting, electrical
outlets, air conditioning, and security of homes, and
answer and open front doors through connection
with intercoms via an app on their smart phone.
Alarms, automated detectors (e.g., falls and seizure),
and emergency call devices/systems provide people
with access to assistance as required. People with
complex health conditions can use devices, sensors,
administration aids, and apps at home to monitor
vital signs, identify changes in performance and/or
behavior, and work with remote health care teams to
prevent an adverse event. Medication management
devices can also ensure people take their medications regularly and send alerts if medication is not
taken. Reminder and scheduling technologies can
also be used to prompt people through scheduled
activities and specific tasks such as their self-care
routine in the bathroom, cooking, and collecting the
mail. A range of high- and low-technology assistive
devices can also assist people in daily activities by
reducing the impact of impairments and conditions/
symptoms and enabling greater participation.
However, these technologies can often be costly
to purchase and support. Without a significant injection of funding into the already strained reserves of
in-home services, they are likely to be overshadowed
by low-technology options or remain a wonderful
resource that is difficult to access. When budgets
are allocated and prioritized, how will intangible and
client-related benefits of environmental modifications hold up against the tangible financial benefits
of in-home monitoring? These technologies also
raise several ethical dilemmas (Tinker, 1999). Whose
needs are being met through these technologies?
What is their effectiveness in reducing the cost of
health care delivery? What impact will they have
on the concerns of well-meaning relatives who want
assurance that their elderly relative is safe? What
role will they play in enabling people to stay safely in
their home environment? Homes are a place of privacy, and intrusive technologies could be resented by
residents and negatively affect the meaning of home
(Heywood, 2004a). Furthermore, there is the possibility that people would be at risk of increased isolation if they are managed and monitored remotely. On
the positive side, new communication technologies
could increase compliance with drug regimens and
summon help quickly if a person has fallen. They can
also put older people and people with disabilities in
touch with people who otherwise may be unavailable to them and provide reassurance that problems
will be relayed quickly to family members or service
providers who can respond. Although there are
many complexities to consider with the advent of
these technologies, occupational therapists are well
placed to implement them effectively and balance
the other needs of the householder with the potential benefits of ongoing monitoring.
In summary, a key value underpinning community
care and occupational therapy services is promoting independence. However, although these services define independence as enabling people to
remain living in their own homes or reducing reliance on others for daily tasks, older people and
people with disabilities generally think of it in terms
of personal control. Recent developments in the
community care sector have provided significant
impetus for the development of home modification services. Although home modification services
remain relatively underdeveloped when compared
with other community care services, they have
been established as being a legitimate part of the
repertoire of community care services designed to
enable people to remain living in the community.
In community care, additive, subtractive, transformative, and behavioral modifications are closely
associated with maintenance and security services.
Administration and coordination difficulties persist
in working across health, social, and construction
sectors, and good intersectoral collaboration is
likely to enhance the development of high-quality
modification services. An understanding of the interaction between people and their living environment
allows modification interventions to be tailored to
the individual’s unique individual circumstances and
promote his or her active participation in the home
and the community.
HOUSING PERSPECTIVE
Many people make changes to their home environments quite independent of health and community care systems. It is therefore useful to examine
how people use generic services to make changes
to their housing, commonly known as housing adjustments, to meet their changing needs and preferences. Throughout life, people encounter changes that
necessitate them relocating or altering their existing housing—whether it is the composition of their
family and household, their health and employment
status, or their interests and lifestyle. Consequently,
people access a range of housing services that thrive
Approaches to Service Delivery
on assisting people to accommodate changes in their
circumstances. Occupational therapists often need
to work with these services or work with people who
use these services to address their ongoing housing needs. In addition, therapists are increasingly
recognizing a role for themselves within a diversity of housing services. Consequently, developing
a broader view of housing adjustments can assist
therapists in understanding home modifications as
part of a continuum of housing arrangements and
anticipating where occupational therapy can contribute to the delivery and further development of
housing services.
From a housing perspective, people alter their
housing or relocate when their existing home no longer meets their changed circumstances or lifestyle
or no longer reflects their tastes or projected image
or identity. Though this view encompasses the
notion of “accommodating a particular set of human
abilities” (the health perspective; Bridge, 2005, p. 2)
or “adapting living environments to increase ease of
use, safety, security and independence” (the community care perspective; Pynoos et al., 1998, p. 3),
it is more universal in scope in that it recognizes
that people make many different types of changes to their housing throughout their lives. These
changes are referred to in the housing literature as
housing adjustments (Howe, 2003; Masnick, Will, &
Baker, 2011), housing careers (Beer & Faulkner, 2008;
Kendig, 1984), housing pathways (Clapham, 2005), or
housing transitions (Beer & Faulkner, 2011). Housing
decisions made in response to a health condition or
changing capacities are unlikely to be made in isolation and are likely to incorporate a range of goals.
Housing adjustments were first described by
Peace and Holland (2001) as the actual changes that
individuals and households make to their housing in
response to their particular needs, circumstances,
and preferences at any point in time. Housing careers
is a term that is used to describe the sequence of
housing adjustments that an individual or household
makes over a lifetime. It is recognized that widespread societal changes, including demographic
changes and improvements in the standard of living,
are transforming established patterns of housing
careers in many countries (Beer, Faulkner, & Gabriel,
2006). Housing pathways describe the “patterns of
interaction … concerning house and home, over
time and space” (Clapham, 2005, p. 27). The concept
of housing careers primarily focuses on changes in
the consumption of housing related to factors such
as age, household structure, income and wealth,
employment, and disability, whereas the notion of
housing pathways places emphasis on the social
meanings and relationships associated with housing
31
(Jones et al., 2008). The pathways perspective views
housing as being more than a set of physical characteristics (i.e., space, layout, condition, access, etc). It
recognizes the meaning that a house might hold for
the occupants, the patterns of interactions contained
within it, and the lifestyle and identity the house
affords its residents (Clapham, 2005). More recently,
the term housing transitions (Beer & Faulkner, 2011)
has been used to capture the fluid and complex
relationship between individuals and their housing,
reflecting the dynamic change that occurs throughout life and placing equal importance on patterns of
housing and the subjective experience of housing.
In addition to providing shelter, home has personal, social, physical, temporal, occupational, and
societal dimensions that contribute to its meaning
and overall experience for individuals (Aplin, de
Jonge, & Gustafsson, 2013). It should be a safe place,
a refuge, and where we have autonomy and control
over the use of space and time (Peace & Holland,
2001). This autonomy allows privacy and the freedom to express oneself. Central to the meaning
of home are the relationships with family, friends,
neighbors, and the community. It is the presence
of these important people and relationships that
contribute to the feeling of home (Sixsmith, 1986).
It is well recognized that housing contributes significantly to quality of life (Pynoos & Regnier, 1997).
The significance of the home is even greater if people
have lived there for many years (Pynoos & Regnier,
1997) or if they spend a considerable amount of time
at home (Newman, 2003). Increasingly, people are
not just interested in finding a house. For many, the
home is both emotionally and financially the single
biggest investment they make in their lives (Hanson,
2001). Consequently, many seek a community that
offers them a distinctive mode of living or a particular lifestyle that enables them to express and define
their identity (Clapham, 2005).
Focus of the Housing Perspective
The housing perspective provides a number of
distinctive insights into housing decisions that have
implications for development and delivery of home
modification services. First, people use a broad range
of strategies when addressing housing concerns.
When making housing adjustments, some have a
strong preference to remain living in their own home
(Peace & Holland, 2001) and current community
(Wiles, Leibing, Guberman, Reeve, & Allen, 2012),
whereas others are willing to relocate in response to
changes in their needs and preferences (Heywood
et al., 2002; Perry, 2012; Stone, 1998). Although home
modification services are recognized as assisting
32
Chapter 2
people to adapt their homes to their changed circumstances (Tinker, 1999), there are some who are
clearly better served by relocating to more suitable
accommodations. It is important to recognize that
housing adjustment, although common in the general
community, is not widely recognized or supported in
health and community care services except in determining when someone needs to move into supported
accommodations. Many modification services tend
to assume that people intend to or should remain
in the current home and leave people to make decisions themselves about relocating and downsizing.
Many people live in homes that constantly challenge
their safety and independence and require a great
deal of upkeep (Tinker, 1999). A home that was once
a “castle” and a reflection of a person’s identity and
status in the community can become a “cage” or millstone, undermining identity and restricting freedom
and lifestyle (Heywood et al., 2002). Little support
is offered to people with the often overwhelming
and complex task of making a housing adjustment,
and the emotional component of relocation is often
neglected (Perry, 2012). Although people who have
made many moves during their lives are well placed
to deal with the financial, legal, and real estate complexities they are likely to encounter, many are not
sufficiently experienced or informed to successfully
navigate these systems. Services with a housing perspective could provide an important way of enhancing the range of options available to people to make
housing adjustments and “enable people to take
control of their pathway through the ability to make
choices” (Clapham, 2005, p. 234). These services
could also manage the complex systems involved in
moving house for people with low incomes or limited
skills or capacities.
Second, the housing perspective has also highlighted that people seek housing that reflects their
identity and lifestyle aspirations. Very few people
consider themselves to be “old” (Wylde, 1998),
and even fewer regard themselves as “disabled”
(Heywood et al., 2002; Wylde, 1998). Consequently,
housing decisions are likely to be shaped by identity and lifestyle choice rather than perceptions of
functional need. The health and community care
approaches tend to favor professionally defined
concepts of functional need, where services are
provided to people; consequently, they are unlikely
to acknowledge people’s lifestyle and identity aspirations (Clapham, 2005). Concern has been raised
about the negative impacts of home modifications
on the meaning of home and the lack of attention to this dimension by home modification services (Messecar, Archbold, Stewart, & Kirschling,
2002). Adaptations to the home can have a negative
impact on routines, self-image, connection with the
home, and a sense of heritage (Heywood, 2005).
Modifications can result in people being viewed as
different and, of greater concern, can make them
vulnerable to ridicule or violence (Fisher, 1998). For
example, a person may be willing to put a grab bar
in his or her own private bathroom adjoining the
bedroom but not in another bathroom that might be
used by guests, where it would bring attention to the
disability and change the decor of their living space.
This underscores the importance not only of choice,
but also of identifying home modifications that are
attractive and acceptable. When making changes in
the home, it is essential that all aspects of the home
environment be considered rather than focusing
solely on the performance of specific self-care tasks
(Heywood, 2005). Acceptance of interventions, such
as assistive devices, has been shown repeatedly to
be influenced by whether they support or undermine the older person’s sense of personal identity
(Harrison, 2004). Householders have been found to
reject modification services if their perspectives and
priorities differ from that of service providers (Gitlin,
Luborsky, & Schemm, 1998) or if they anticipate that
the changes will affect their sense of independence
and autonomy (Messecar et al., 2002).
Third, when building or remodeling housing, there
are opportunities to plan ahead to pay particular
attention to areas such as entrances, pathways, lighting, kitchens, and bathrooms. This is an ideal time
to bring together occupational therapists, remodelers, architects, and interior designers to work as a
team to help people plan ahead in terms of thinking
about aging in place and adding features that might
help them stay in their homes. For example, when
remodeling, a resident could install a zero-step
entrance, install a walk-in or roll-in shower instead
of a conventional bath or shower/bath combination,
and fit cabinets in the kitchen that are within easy
reach or provide somewhere to sit down to prepare
food. These types of features might be found in a
universally designed house but can be incorporated
into existing homes as well. In addition, rather than
considering the dwelling’s suitability solely for the
resident, it should be seen as a place where others of
varying abilities visit. This aspect incorporates the
communal nature of housing and underlies the charter of the visitability movement, which has made
advances in both England and, to a lesser extent, the
United States.
Key Stakeholder Roles and Perspectives
Although involved in both health and community
care approaches to home modifications, building
and design professionals are central to the housing
Approaches to Service Delivery
perspective. Their services are essential when considering the remodeling of a home, undertaking
major renovations, or constructing a new dwelling.
It is important when working with building or design
professionals that occupational therapists understand that all professions have an embedded culture,
which includes the norms, values, beliefs, traditional
knowledge, skills, and core practices that guide and
shape professional behavior and identity (Watson,
2006). It is into this culture that new professionals
are socialized through education, training, and work
experiences. Understanding the cultural orientation
of a profession is important in understanding how
professional reasoning and decision making occur.
The building profession has a culture that is
strongly embedded in a regulatory environment.
It is an industry that is prescribed, regulated, and
inspected—and rightly so, given the issues of safety
that are involved. This perspective is extremely
valuable to home modification services delivery
because the building professional is able to advise
what is possible and not possible in accordance
with various codes and regulations within a home
environment. The downside of this, however, is that
standard responses to an individual’s needs can
become entrenched, and documents such as public
access standards can be given a higher priority than
is practicable or advisable in a unique and dynamic
individual situation (Pynoos et al., 2002).
Accessibility codes are typically designed to
determine minimal legal guidelines for public access
and have a stereotypical view of the end user (e.g., a
user of a wheelchair). They have very little to do with
the needs, aspirations, desires, and uniqueness of a
particular individual and do not cater to the many
variations of individual functioning of people who
have a disability (Danford & Steinfeld, 1999; Imrie &
Hall, 2001). For example, current public access standards in many countries are not based on research
for older people, and the assumption that designing
for wheelchair use will also meet the needs of an
older person with a range of mobility requirements
is an untested hypothesis that has not been evidenced in research. In fact, research in the United
States has shown that some modifications to the
existing accessible standards “may promote more
disability among older adults than it ameliorates”
(Pynoos et al., 2002, p. 16).
Architectural or technical aspects are emphasized
by building professionals, with the home dwelling
considered a “piece of hardware” and the personal
and social aspects of home disregarded (Imrie, 2006,
p. 14). In this way, technical knowledge dominates
the construction professional’s decision making and
actions. Many building professionals have time and
33
money constraints and can be financially vulnerable,
particularly if they are subcontractors. Tradition
also plays a strong role in the builders’ work, with
many being resistant to changing the way they do
their work (Burns, 2004).
Current literature suggests that the construction
industry in many countries does not respond well
to the needs of people with a disability and that
formal education of building professionals on the
needs of people with a disability is “more or less
non-existent” (Burns, 2004; Imrie, 2006; Imrie & Hall,
2001, p. 6). Imrie and Hall assert that “inattentiveness to and exclusion of the needs (of people with
a disability) are evident at all stages of the design
and development of the built environment” (2001, p.
6). The house building industry has been characterized by a lack of innovation and a “poorly developed
sense of customer focus when compared to other
service sectors” (Burns, 2004, p. 768). This lack of
interest or willingness to be innovative has resulted
in a standardization of house design where “certain
household types and certain bodies are targeted”
(Burns, 2004, p. 769). The drive for standardization
has been linked to the rise of large-scale corporate
property development in which standardized fittings
and fixtures are commonplace and the construction
“revolves around industry standards, which are
inattentive to bodily diversity or differences” (Imrie
& Hall, 2006, p. 9). Older people and people with a
disability often have requirements that are not met
by standard housing designs and thus provide builders with challenges to their traditional designs and
techniques (Burns, 2004).
Within the professional culture of the design
professions, such as architecture or interior design,
designing for the needs of people with a disability
has not been a significant feature of design theory or
a major part of the design and development process
(Goldsmith, 1997; Imrie & Hall, 2001; Liebermann,
2013). The focus of the design process tends to be
aesthetics and technical cleverness more than the
user or functionality of the building (Goldsmith,
1997), with “the concern of the decorative and the
ornamental” remaining a “powerful part of the
design professions” (Imrie & Hall, 2001, p. 12). Where
the needs of people with a disability have been
incorporated into a project, “there is the tendency
to reduce disability to a singular form of mobility
impairment, that of the wheelchair user” (Imrie &
Hall, p. 10; Liebermann, 2013).
Within the architectural profession, there have
been, and continue to be, challenges to the dominant
design culture. Imrie and Hall (2001) use the terms
social architecture and social design to describe a
trend that proposed to “recognize the multiplicity
34
Chapter 2
of needs of building users” and the need to accommodate them in building projects (p. 12). This movement has sought to recenter the design process on
the user of the building and to incorporate a broader
and more holistic understanding of the needs of
users of the buildings. The core values of social
design align with environmental and social justice
and human rights; however, Imrie and Hall report
that the movement has had little impact on the thinking of the design professions in relation to people
with a disability.
Inclusive design and universal design are similarly
social movements that have gained prominence in
both the United Kingdom and the United States.
Inclusive design, like the social design movement,
is concerned with the “sustainability, flexibility and
adaptability” of buildings to accommodate the diversity of building users, placing the user of the building in the center of the design process (Milner &
Madigan, 2004, p. 734). Universal design is concerned with making products and environments as
usable as possible to the broadest range of users.
Applied to housing, universal design far exceeds the
minimum specification of access standards, seeking
to create homes that are “useable by and marketable to people of all ages and abilities” (Mace, 1998,
p. 22). This type of design process is in contrast to
the compensatory approach in which elements of
accessibility are added on to previously inaccessible
or standard designs (Imrie & Hall, 2001). Although
universal design has been widely accepted and
is endorsed by global agencies such as the WHO
and United Nations (Imrie, 2012), it is “yet to make
an impact on mainstream architectural practice”
(Liebermann, 2013, p. 14).
Though professional orientation and culture
differ between building and health professionals,
they are complementary, and consideration of each
stakeholder’s perspective is important in establishing good communication, understanding, and
effective outcomes. Clear and ongoing communication is the best strategy to facilitate a good working arrangement. It is helpful for the therapist to
have a basic understanding of building terminology to be able to understand to some extent the
construction issues involved with the modification
process. Asking questions and getting clarification are important. Often, therapists need to work
through alternative solutions on site with the building professional so that they can fully understand
the regulatory requirements and engage in problem
solving to explore how performance requirements
might be met differently. Therapists also need to
communicate their recommendations clearly, both
when speaking and writing.
The therapist also has a responsibility to ensure
that the individual and his or her needs remain the
focus of the work carried out. The therapist needs to
ensure that the individual, as the expert of his or her
life, is recognized and that his or her thoughts, ideas,
and wishes are not overwhelmed by the technical
discourse of the building and design professional.
Although there is excellent scope for collaboration, differences in professional culture can also lead
to situations of conflict, and good conflict resolution
skills are an important part of the occupational
therapist’s repertoire. Assertive communication that
provides, in plain language, the professional reasoning that informs the opinions and decisions
regarding occupational therapist recommendations
is essential to ensure good understanding and communication.
In summary, from a housing perspective, people
make adjustments to their housing throughout life
in response to their changing circumstances. These
adjustments can include making changes to the current dwelling or seeking alternative living environments. Increasingly, housing decisions are shaped
by a quest for a particular lifestyle that allows
people to express and define their identity. This perspective alerts occupational therapists to the need
to consider people’s housing concerns more broadly,
to ensure that they are afforded adequate choice,
and to ensure that they are provided with sufficient
information and support that reflects their housing
needs and preferences into the future. Furthermore,
it reminds the profession to recognize people’s aspirations and the personal nature of the home environment when undertaking modifications.
FUTURE CHALLENGES FOR HOME
MODIFICATION SERVICE DELIVERY
Strategic Policy Direction
Awareness of the benefits of home modifications
has been increasing; however, there are still significant challenges to the viability and usefulness
of home modification service delivery. Emphasis at
a legislative and strategic policy level is on implementing change in new construction, as seen by the
increase in visibility legislation in most developed
countries. Although moves toward inclusive and
universal design are gaining momentum at an international level, significant issues still face those living
in existing inaccessible and unsafe housing.
At a strategic policy level, there is a need for
greater recognition of the importance of home
Approaches to Service Delivery
35
modification to community living for people with a
disability and for our increasingly aging population.
In many countries, home modification services are
intrinsically linked to health and community care
policy areas. A report from the Office for Disability
Issues in the United Kingdom (Heywood & Turner,
2007) highlighted four main ways in which the
provision of housing modifications and equipment
produces savings to health and social care budgets.
These were savings in the cost of residential care
through enabling people to remain in their homes
and reducing the cost and need for in-home care services; savings through the prevention of accidents
with associated high costs of hospital and residential care admissions; savings through prevention
of waste brought about because of underfunding
of modification services, which resulted in delays
in implementation and provision of inadequate or
ineffectual solutions; and, finally, savings through
achieving better outcomes for the same expenditure
by improving the quality of life of recipients and
caregivers and family members (Heywood & Turner,
2007). Though the report found evidence of the preventive and therapeutic role of home modifications,
it also highlighted the ongoing issue of underfunding
for home modifications and increasingly restrictive
eligibility criteria related to this, reducing the availability of home modifications to many people who
would benefit (Heywood & Turner, 2007).
As indicated previously, Jones et al. (2008) believe
that there is a strong case for reconsidering the current approach to the organization of home modification services and suggest that the future of home
modification service delivery may lie in the recognition that home modification services are a major
contributor to the housing policy area, rather than
being seen primarily under the banner of health
and community care policy areas. Aligning home
modification services with strategic housing policy
links the home modification service to the areas of
accessible and inclusive housing and national strategies for housing, while still maintaining links to the
health and community sectors (Jones et al., 2008).
In this way, strategic policy direction that provides
a coordinated funded service delivery response
across public and private housing and also links
housing into health and aged care services may be
more achievable.
ago. First, although there is an increase in the organizations and programs funded to provide home
modification services, there is a lack of a systematic
approach to the organization of such services, with
limited policy development, few benchmarks for
service delivery, and great disparities in the level of
service provision (Jones et al., 2008; Pynoos et al.,
1998; Sorenson, 2012). Resourcing is considered to
be insufficient to meet demand, and lack of funding
results in delays in work being carried out (Jones et
al., 2008; Pynoos et al., 1998). Services and service
recipients are often overwhelmed by the cumulative
impact of numerous building, health, disability, and
legal requirements (Awang, 2002; Jones et al., 2008;
Sakellariou, 2015), which are in themselves barriers
to accessing and delivering an effective home modification service.
Although levels of expertise have developed over
the past decade, there are still shortages in skilled
professionals from both the health and construction
sectors that contribute to delays in service provision (Sorenson, 2012). A lack of awareness about the
advantages of home modification continues to exist
within both the community and service sectors,
resulting in unreliable referral processes (Jones et
al., 2008; Pynoos et al., 1998).
Though many issues exist, research has shown
overwhelmingly that home modification services
are well received, and positive outcomes such as
improved independence, heightened confidence and
well-being, greater security, prevention of accidents,
and improved quality of life are generally reported
(Heywood & Turner, 2007; Jones et al., 2008; Keall et
al., 2015; Petersson et al., 2008). There is, however,
a clear need for the continued development of a
research evidence base to underpin home modification services development and delivery, particularly
in the areas of the need and demand for home modification services; the outcome and cost-effectiveness
of home modification as an intervention; and the
identification of particular factors that affect service provision and outcomes, including the supply
of expert professionals (Heywood & Turner, 2007;
Jones et al., 2008).
Service Design and Delivery
Direction
Involvement with home modification services
delivery presents new challenges to occupational
therapists, both in the knowledge base they need to
acquire and in the professional sectors with whom
they collaborate. Effective home modification service delivery relies on ensuring that the individual
and his or her unique and particular needs remain
At a service level in the United States and Australia,
many of the issues facing home modification service
delivery today were being raised more than a decade
Implications for the Occupational
Therapist
36
Chapter 2
central to the assessment and decision-making process, and the occupational therapist has a key role in
ensuring that this occurs.
Although the focus of occupational therapy has
traditionally been on the individual receiving his or
her service, therapists are increasingly being challenged to step outside of their conventional clinical
roles and become involved in home modification service delivery as agents of change. First and foremost,
occupational therapists are well placed to observe
the effect of policy and procedural issues on individual service delivery. Poor communication and information about home modification service delivery
and complex application procedures and forms are
key barriers to effective home modification service
delivery against which therapists can advocate for
change. Establishing and undertaking formal evaluation processes, seeking and recording individual
client feedback, and providing reports of concerns
to the relevant people within organizational structures are all strategies that can be undertaken by
individual therapists.
A lack of awareness of the benefits of home modifications is another identified barrier that occupational therapists can assist in addressing. Therapists
can play a key role in the education of both community and service sectors regarding the benefits
of home modification through both formal presentations about the home modification service to client
and referral agencies and through informal professional networking.
Building an evidence base for intervention in this
area is also an important role for the profession.
Quality research into the outcomes of home modifications from the perspective of the home dweller
and evaluating the effectiveness of home modification service delivery are areas that occupational
therapists are well equipped to address. Engaging
in formal evaluation of environmental interventions
can yield important data that can be formulated into
reports, publications, or professional presentations.
Linking with agencies or institutions that may be
interested in undertaking formal research, such as
universities, is also advantageous for therapists in
terms of professional development, as well as building a much-needed evidence base for practice.
CONCLUSION
Recent demographic, legislative, policy, and service developments have resulted in a range of services being created to promote people’s safety, health,
independence, and well-being in the home environment. Occupational therapists have an important
contribution to make in enabling people to live well
in the home and community and need to work effectively within and across health, community care, and
housing systems to achieve good outcomes for their
clients. Home modification services developed in
the health care system are primarily concerned with
ensuring safety and enabling independence through
the use of minor or nonstructural modifications.
Health-based services perceive the home as a physical entity that needs to be modified to accommodate
functional deficits, and in so doing, therapists can
overlook the long-term suitability of a residence;
the social acceptability of modifications; and issues
of identity, meaning, and lifestyle when designing
interventions. Therapists working in this context
need to be mindful of the personal, temporal, social,
and cultural nature of the home environment when
addressing physical aspects of the environment.
Within community care services, behavioral, nonstructural, and structural modifications are used in
conjunction with a range of other services to support
people to live safely and independently in the community. An understanding of the interaction between
the person and his or her living environment allows
modification interventions to be tailored to the individual’s unique circumstances and promote his or
her active participation in the home and the community. Therapists working in community care settings
need to work across health, social, and construction
sectors to develop good intersectoral collaboration
and enhance the development of quality modification services.
Services developed within the housing sector
acknowledge that people make adjustments to their
housing throughout life in response to their changing circumstances. Within this sector, modifications
are seen as part of a continuum of adjustments,
which can also include seeking an alternative living
environment that better suits the individual’s identity and lifestyle aspirations. Within this perspective,
occupational therapists are encouraged to consider
people’s broader housing concerns, to provide clients with sufficient information and support when
making adjustments, and to help clients think ahead
in terms of the suitability of modifications to help
them age in place.
Clients are likely to be seeking to maintain their
safety, health, and well-being as well as their identity and lifestyle within the home and community,
regardless of where they access home modification
services. Therapists need to be aware of the context
in which they work, the way this can shape their
service delivery, and the importance of extending
their service to acknowledge clients’ broader needs
or referring them to a service that is better suited to
Approaches to Service Delivery
addressing their needs. Furthermore, professionals
such as occupational therapists and the organizations that represent them have an important role to
play in improving the policies that affect their practice and the lives of the clients they serve.
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Models of
Occupational Therapy
3
Desleigh de Jonge, MPhil (OccThy), Grad Cert Soc Sci
and Merrill Turpin, PhD, Grad Dip Counsel, BOccThy
Models provide a framework for thinking and
clinical decision making. They make explicit the
profession’s scope of concern (and, therefore, role)
and how it identifies and understands issues and
problems, and they provide a structure for systematic and comprehensive practice (Turpin & Iwama,
2011) that guides notions of appropriate evaluation
and intervention strategies and ways of evaluating
outcomes. A number of occupational therapy models
of practice have been developed over the years that
assist occupational therapists in understanding the
difficulties individuals are experiencing and the factors that contribute to them. Each model of practice
conceptualizes the person, occupation or performance, environment, and interaction between these
in different ways, all of which have an impact on
how occupational therapists engage with issues and
implement occupational and environmental interventions. This chapter reviews four key approaches
used by occupational therapists when undertaking
home modifications and examines how each shapes
home modification practice and outcomes. The chapter describes the rehabilitation model, Canadian
Model of Occupational Performance and Enablement
(CMOP-E), ecological occupational therapy models,
and Kawa model and examines how each contributes
to our understanding of how people engage in meaningful occupations in the home and community. Also
examined is the evolution of occupational therapy
practice models and their relevance and integrity
in light of politico-sociocultural trends, such as the
shift to a social model of disability and the development of client-driven services.
CHAPTER OBJECTIVES
By the end of this chapter, the reader will be able
to:
Ô Describe how models have shaped occupational therapy practice in the area of home
modifications
Ô Describe how the rehabilitation model, CMOP-E,
ecological models, and Kawa Model structure
practice
Ô Identify the strengths and limitations of each
of these models with respect to home modification practice
INTRODUCTION
As a profession, occupational therapy continues
to evolve in response to scientific advancements,
- 41 -
Ainsworth, E., & de Jonge, D. An Occupational Therapist’s
Guide to Home Modification Practice, Second Edition (pp. 41-61).
© 2019 SLACK Incorporated.
42
Chapter 3
as well as philosophical shifts in society and within
particular service contexts. Changes in the scope
and focus of the profession are clearly evident in the
successive models of practice developed to guide
and describe occupational therapy practice. Models
reflect our thinking and shape our practice (Duncan,
2011) and can be described as being conceptual or
procedural in nature. Conceptual models are usually
presented in a graphic form, overviewing concepts
and describing the relationships between the identified elements. This type of model defines the domain
of concern of a profession and assists a professional
to think about and interpret situations (Turpin &
Iwama, 2011). In contrast, procedural models specify
a procedure for attending to issues and elements,
directing the process at a very practical level. To
illustrate the function of each of these models, imagine you were to plan a trip using a map. A map is like
a conceptual model, outlining the boundaries of the
geographical area to be explored, various places of
interest, their spatial relationships, and their means
of connection. Because many of us travel with a finite
amount of time and financial resources in mind, we
also need to develop a travel schedule (procedural
model) so that we can visit all of the important landmarks and plan a methodical and efficient route of
travel. Although you might be able to undertake your
trip using only one of these approaches, using both a
map and a schedule enhances your understanding of
the destination and use of relevant resources.
The same is true when using models in practice.
Occupational therapists need both conceptual and
procedural models to practice effectively. Many
occupational therapy models are predominantly
conceptual, requiring therapists to develop their
own plan of action. Other models are largely procedural, requiring occupational therapists to bring
their own understandings of the broader picture,
elements of concern, and inter-relationships. Many
frames of reference and service models provide
this structure. Effective practice relies on having an
understanding of all of the areas of concern and their
interactions as well as a plan of operation. It is also
essential that both the procedural and conceptual
models align with and are relevant to each other.
There is little point in having a map of the whole of
Europe if you confine your trip to Italy. Also, it would
be difficult to convince people you have seen Europe
if you have traveled only from Rome to Florence,
and it would be challenging to navigate between
and within small villages if your map only has the
major highways marked. Without an appropriate
map, your travel experience would not reflect your
intentions, nor would it live up to your expectations.
Equally, occupational therapists need to ensure that
their actions echo their stated focus and goals. This
requires that they have sufficient understanding of
the issues they are dealing with (conceptual model)
and that these are reflected in an appropriate plan of
action (procedural model).
Occupational therapists tend to use different
models of practice, either implicitly or explicitly,
depending on their primary area of practice, where
and when they were trained, and the models they
relate to personally. Additionally, service environments and reimbursement schedules have their own
procedures, which can affect the focus and scope of
practice and can influence occupational therapists’
choices of model or shape the way they are operationalized. Consequently, they need conceptual models to help them maintain their discipline focus and
embed the philosophy and values of the profession.
Many occupational therapists are not aware of
the models or other influences shaping their practice. They generally operate intuitively on internalized understandings (Owen, Adams, & Franszen,
2014; Reed, 1998) or use well-practiced and routine
approaches to address issues. As a result, they
select and use assessment tools and interventions
without necessarily being aware of the beliefs and
attitudes directing these decisions. Regardless of
whether they are conscious of the models directing their actions, they hold their own views about
people and have particular understandings of the
cause and impact of impairment or disability. These
views delineate their scope of concern; determine
the nature of services they offer; and dictate how
they work with clients, define and evaluate needs,
and focus their interventions. Without a clearly
identified model to define the scope of practice and
provide a systematic approach, practice is reliant
on personal experience, habits, and routines that
may not be comprehensive (Turpin & Iwama, 2011).
This can make it much more difficult to individualize solutions and negotiate good client outcomes.
Models can maximize learning from experience by
alerting therapists to the limitations of their current
understandings and prompting them to extend their
knowledge and skills.
Occupational therapists who are conscious of
their conceptual model can explain their unique
contribution to the team, describing their expertise or justifying their approach. When they find
themselves in conflict with clients or other service
providers who might have different understandings
or expectations, they can consider the situation and
are able to explore the other person’s perspective,
articulate their own perspective, and identify common goals. Therapists who acknowledge or reflect
on their model of practice remain alert to the scope
Models of Occupational Therapy
of concern of the profession and select assessment
and intervention approaches that address these concerns. With a clear and well-articulated conceptual
model of practice, therapists are able to prioritize
clients’ specific needs over service imperatives
and processes. These therapists are also able to
recognize and respond to conceptual developments
and new knowledge in an area of practice. There is
harmony between what they say they do and what
they actually do because their procedures are well
aligned with their conceptual model.
It is therefore important that therapists be aware
of the concepts shaping their practices and driving
their decision making. To illustrate the impact of
models on the nature of services provided and the
outcomes achieved, this chapter examines each
model of practice in turn, using the following case
study of Mrs. Hume. The way in which each model
of practice shapes service delivery and determines
outcomes will be described and analyzed with particular reference to their capacity to respond to client concerns and to deal with important aspects of
the home environment.
Mrs. Hume is an 82-year-old woman who lives in
a four-bedroom detached house in an older outercity suburb. She has lived in this neighborhood for
60 years, having raised her family in the two-story
house her husband built soon after they were married. When her husband died 5 years ago, her previously widowed sister (now 80 years old) moved in.
Mrs. Hume has three children—a daughter who lives
10 miles away in the same city, a son who lives in a
nearby city, and another son who has moved interstate. She has rheumatoid arthritis and has been
admitted to the hospital following a recent flare-up
of her condition. Medication has been re-evaluated,
and her condition has settled. She has been referred
to occupational therapy to assist in her return home.
Before reading any further, take a few moments to
reflect, as her occupational therapist, on this case
and write down what you would offer Mrs. Hume.
Consider the following questions:
Ô What would be your main focus?
Ô How would you determine need?
Ô How would you address needs?
Ô How would you work with Mrs. Hume?
Ô How do you view the home environment?
Ô What outcomes are you expecting from your
interventions?
The way occupational therapists regard Mrs.
Hume, relate to her and her home environment, and
define and address her needs reveals much about
the model of practice from which they work. As
43
you read through this chapter, you may recognize
aspects of models evident in the approach you
identified in relation to Mrs. Hume. Through the discussion of each of these models, you should come
to appreciate the impact of your current conceptualizations on the nature of the services you would
provide, how you would go about providing them,
and the subsequent outcomes you could achieve for
Mrs. Hume. In addition, you will be able to reflect
on contemporary views of disability and illness, the
environment, and person-centered practice, as well
as how well these understandings are reflected in
your current practice.
REHABILITATION MODEL
Occupational therapy, originally embedded in
a humanistic tradition (Schwartz, 2003), has been
strongly influenced by medical science and biomedical models of practice. Following World War
II and the emergence of rehabilitation medicine,
occupational therapy joined other allied health
professionals in providing medical care to returning
soldiers. By the 1970s, with the proliferation of scientific knowledge and expansion of the health care
industry, and as a result of the Rehabilitation Act of
1954, occupational therapy was well established in
rehabilitation services (Schwartz, 2003).
The rehabilitation model is founded on extensive knowledge of the structure and function of
the human body and the impact of injury and disease. This model has had an enduring influence on
the way people with disabilities and illnesses are
viewed and their needs defined within rehabilitation
services. Within this model, people are considered
human organisms consisting of a series of complex
systems, with underlying structures and functions
that are common to all humans. Traditionally, medical specialists and rehabilitation professionals have
defined their scope of concern or responsibilities in
terms of particular body systems (e.g., cardiologists
are responsible for matters concerning the circulatory system and neurologists focus on the neural
system). Similarly, allied health professionals tend
to define their roles in terms of functional systems: physiotherapists are primarily concerned with
neuromuscular function, psychologists with mental
function, and speech-language pathologists with
voice and speech function (Seidel, 1998). The initial
focus of rehabilitation was to restore an individual’s
function when his or her capacity had been altered
or limited by a physical or mental impairment that
could not be remediated by surgery or medical
intervention (Seidel, 1998). However, this model has
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Chapter 3
continued to evolve in response to social changes,
such as deinstitutionalization and the Independent
Living Movement (Schwartz, 2003), resulting in a
shift to promoting independence. Consequently,
occupational therapists have focused on restoring
the individual’s ability to function independently in
daily activities.
Within this model, the primary challenge to occupational performance is impairment, which is defined
as the “loss or abnormality of psychological, physiological or anatomical structure or function” (World
Health Organization [WHO], 1980, p. 47). Disability
is understood as a restriction or lack of ability to
perform an activity in a manner or within the range
considered “normal” (Seidel, 1998). Assessment is
therefore focused on identifying specific symptoms
and signs of abnormality and quantifying the person’s functional capacities in various areas, such as
neuromuscular, mental, or cardiovascular, as well
as independence in daily activities. The rehabilitation model requires the combined and coordinated
use of medical, social, educational, and vocational
measures to train or retrain an individual to the
highest possible levels of function (WHO, 1980).
Interventions involve retraining and the use of remedial activities to restore function, compensatory
techniques to support the completion of tasks and
activities (when restoring function is not possible),
and assistive devices and environmental adaptations to accommodate lost function.
In a rehabilitation model, the degree to which
maximum function and independence can be
achieved is believed to be largely dependent on
the individual’s level of motivation. The therapist is
conceptualized as an expert who brings specialist
knowledge about the physiology and pathology of
impairment to the process and educates the individual about appropriate remediation and adaptive
strategies (Dewsbury, Clarke, Randall, Rouncefield,
& Sommerville, 2004). Occupational therapists intervene to regain lost function and prescribe suitable
compensatory techniques, assistive devices, or environmental adaptations to promote independence.
Typically, assistive devices are recommended more
frequently than environmental adaptations because
these interventions are both less costly and less
complex to implement (Auriemma, Faust, Sibrian,
& Jimenez, 1999; Pynoos, Tabbarah, Angelelli, &
Demiere, 1998; Tabbarah, Silverstein, & Seeman,
2000). Within this model, the environment is seen
as a static physical entity that can be modified to
accommodate an individual’s identified functional
impairments. When considering the environment,
the focus is largely on aspects that create barriers to
independence in specific self-care activities, such as
mobility, bathing, and toileting. The outcomes generally sought by therapists and services using a rehabilitation approach are for the person to regain maximum function and independence. Consequently,
outcome measures focus on evaluating the extent of
the person’s independence and change in functions
believed to underpin independence (often measured
by comparing the same assessments at baseline
and therapy end). Because independence is defined
as being able to complete tasks without assistance
(Tamaru, McColl, & Yamasaki, 2007), many outcome
measures seek to determine the extent to which individuals can complete tasks on their own.
Addressing Mrs. Hume’s Home
Modification Needs Using a
Rehabilitation Framework
In light of the previous description of the rehabilitation model, how would a therapist using this model
address Mrs. Hume’s home modification needs?
The following questions will be used to guide this
analysis:
Ô What would be the therapist’s primary focus?
Ô How would a therapist using this model define
Mrs. Hume’s challenges?
Ô What evaluation processes would be used with
Mrs. Hume?
Ô What interventions or services would be available to Mrs. Hume?
Ô How would the therapist work with Mrs. Hume?
Ô How would the environment be addressed in
this model?
Ô What outcomes would Mrs. Hume expect to
achieve?
The extensive scientific and medical knowledge
underlying the rehabilitation model would ensure
that Mrs. Hume receives the very best medical care.
This means that health professionals would actively
manage her condition and that she could expect
reduced inflammation, pain, and long-term damage
to her joints. She would be under the care of a rheumatologist for the management of her arthritis and
would be referred to other specialists as required.
She is likely to be receiving the service of a physiotherapist to maximize her range of movement and
muscle strength, and she is likely to be referred to
an occupational therapist to maximize her function
and independence in activities associated with daily
living. She may also be referred to a hand therapist—or possibly a physiotherapist or occupational
Models of Occupational Therapy
therapist—for splints to protect her joints. Within
the rehabilitation model, Mrs. Hume would be identified primarily in terms of her health condition and
would be provided services in line with protocols
for that condition. Evaluation would commonly focus
on defining her level of function, including measures
of range of movement, grip strength, and independence. Mrs. Hume is also likely to receive ongoing
evaluations of her physical and functional capacity
as successive health professionals establish a baseline and periodically re-evaluate her condition to
note improvements in her response to medications
and remedial exercise and activities.
With a clear understanding of the health condition and its prognosis, the therapist would develop
a treatment plan for Mrs. Hume and educate her
about regaining function and maximizing independence. The goal of interventions would be to achieve
maximum function, and Mrs. Hume is likely to be
given exercises, taught compensatory joint protection strategies, and provided with splints and assistive devices to allow her to complete the activities
of daily living (ADLs) considered “normal” for adults
her age (e.g., all adults are expected to be independent in toileting). Assistive devices such as reachers
and tap turners would commonly be recommended
based on her diagnosis of rheumatoid arthritis
(Mann & Lane, 1995) or in response to particular
activity difficulties. Specific barriers to completing
self-care activities in the home (e.g., low toilet and
standard tap and door fittings) would result in recommended home modifications, such as installation
of grab bars or lever taps and handles. The therapist might or might not make a home visit because
potential environmental barriers could largely be
determined from Mrs. Hume’s known impairments,
from identified functional capacities and performance difficulties in daily activities, and through
discussion with Mrs. Hume about features in the
home. Mrs. Hume would receive advice from the
therapist about appropriate remedial strategies to
continue with at home, as well as suitable assistive
devices and modifications. Lack of compliance with
recommended interventions would be attributed to
Mrs. Hume’s lack of motivation or understanding of
her condition and the purpose of the interventions.
In response, the occupational therapist would seek
to educate Mrs. Hume about her condition and the
benefits of adhering to recommendations. It would
be anticipated that the recommended interventions
would allow Mrs. Hume to function independently in
self-care activities. Follow-up evaluations might be
undertaken to confirm that she is completing tasks
independently.
45
Implications of Using the
Rehabilitation Model for Home
Modifications
The rehabilitation model is not specific to occupational therapy, but it is a pervasive model in health,
shaping the way health is understood and services
are organized. However, the extensive knowledge
of body structures and functions that underlies the
rehabilitation model allows occupational therapists
using this model to reduce the amount of residual
impairment resulting from an injury or health condition and promote high levels of function and independence. Having grown out of a medical model, the
rehabilitation model uses a “medical” or individual
model of disability, which sees disablement as a
personal problem resulting from disease, trauma, or
other health condition and requiring care and individual treatment by medical professionals (WHO,
2001). Consequently, much of the evaluation process
is focused on determining the degree of a person’s
impairment or specific deficits. Measures of function either rely on personal interpretations of normal
function or refer to data that detail the maximum
or average for any given age group. However, little
is known about the strength or range-of-movement
requirements for everyday tasks (Badley, 1995; Law
& Baum, 2005), and assessment results might overor underestimate the specific requirements of particular tasks for any given individual in his or her
environment (Dunn, 2005). A deeper understanding
of the specific difficulties someone experiences in
daily activities would ensure that interventions are
more appropriately tailored to the individual.
Often, many people are involved in providing specialized care and addressing specific deficits. This
can leave the affected person feeling overwhelmed,
fragmented, and disempowered. A focus on presenting physical problems can also mean that social and
emotional needs are not acknowledged well within
this model (Seidel, 1998). Evaluation and treatment
protocols tend to focus on specific functions and
often do not allow the occupational therapist to
develop an understanding of the real person and
their concerns and priorities. Rehabilitation goals of
maximizing function and independence often take
precedence over the client’s unique concerns and
goals. Whereas occupational therapists are concerned with ensuring that people can function without help, clients might be more worried about having
control over their daily activities and making lifestyle
decisions (Clough, Leamy, Miller, & Bright, 2004;
Heywood, Oldman, & Means, 2002). Consequently,
46
Chapter 3
devices or modifications recommended by a rehabilitation therapist to promote independence in the
shower, for example, might not be acceptable to the
client because he or she might be more interested in
conserving time and energy to engage in other chosen activities rather than being exhausted by routine
self-care tasks. When clients do not embrace the
interventions offered, it is often perceived that they
lack motivation or understanding. However, because
the professional largely determines goals and interventions with specific reference to the individual’s
performance deficits (Law, 1998), they might not
be well suited to the person’s requirements, preferences, or lifestyle.
It is often difficult for clients to shape and direct
intervention in the rehabilitation model because
therapists are usually the ones who have extensive
knowledge of the injury or health condition, its
pathology, and how it can be remediated. In addition, clients usually have little knowledge of the
interventions available and are reliant on the expertise of the therapist for recommendations. Although
it would be helpful to use this opportunity to educate
the client about alternative options and their relative
benefits, the focus instead is on increasing compliance (Law, 1998), assuming that once the person
understands why the intervention is considered necessary, he or she will automatically accept it.
In the rehabilitation model, restoration of function is usually the primary focus of treatment, with
remediation strategies, such as assistive devices and
home modifications, receiving less attention. In the
hierarchy of rehabilitation interventions, these strategies are frequently seen as part of discharge planning, and there is often insufficient time to effectively
plan and implement the intervention before the person is discharged. With interventions focused primarily on a client’s specific performance difficulties,
little attention is given to how the environment can
support and promote further engagement in activities. The restricted view of the environment as a
physical entity means that its personal, cultural, and
social aspects are often overlooked. Consequently,
interventions might not be tailored as well as they
could be to the home environment and could create
challenges for the client and others instead.
The outcomes of rehabilitation are generally
defined and evaluated by service providers (Law,
1998) and are traditionally focused on achieving a
specific performance standard or complete independence. It is difficult to measure the success of
modification outcomes, especially in terms of independence achieved, using the standardized tests
currently in use because many measures of independence assign a penalty for using any assistance,
including a device. For example, when using the
Functional Independence Measure (Uniform Data
System for Medical Rehabilitation, 1997), people
can only achieve the highest score of 7 if they do
not use a device or have any assistance to complete
the task (Cook & Hussey, 2002). In addition, rehabilitation outcome measures such as the Functional
Independence Measure do not assess the value of
activities for the individual or the quality or acceptability of performance.
OCCUPATION-BASED MODEL
In an effort to differentiate itself from other health
care professions and to articulate its unique scope
of concern, occupational therapy developed its own
models and frameworks for practice. These models aimed to unify the profession, which had been
fractured by an explosion of new knowledge about
the internal workings of the body and psyche and
increasingly specialized practice structured around
medical conditions. An overemphasis on techniques
and the use of modalities prompted the profession
to re-examine its direction and to reconnect with
its original philosophy, beliefs, and focus on occupation (Schwartz, 2003). Occupational performance,
a term first coined in the American Occupational
Therapy Association (AOTA) grant report in 1973,
became the unique and central concern of the
profession because it focused on individuals’ abilities to accomplish tasks related to their roles and
developmental stage (AOTA, 1973; Reed, 2005). The
Occupational Performance Model (OPM) was one of
the earliest occupational therapy models to evolve
from this shift in direction. It grew out of a series of
AOTA task forces and committees in the 1970s and
the writings of leaders in the profession about that
time, such as Llorens, Mosey, and Reilly (Kielhofner,
2004; Llorens, 1989; Mosey, 1981; Pedretti, 1996). The
OPM was primarily structured around the concepts
of performance components (sensorimotor, cognitive/cognitive integration, psychosocial/psychological) and performance areas (ADLs, work/productive
activities, and play/leisure). Figure 3-1 displays a
graphical representation of the OPM as presented by
Pedretti (1996). Failure or disruption in performance
areas (ADLs and work/productive activities or play/
leisure) are assumed to result from deficits in performance components, task learning experience, and/
or an unsupportive life space or context. The temporal/environmental performance context (physical,
cultural, and social) is acknowledged as important
to successful occupational performance but is not
developed as an integrated concept.
Models of Occupational Therapy
47
Figure 3-1. OPM. (Adapted with permission from Occupational therapy: Practice
skills for physical dysfunction, Pedretti, L. W.,
Occupational performance: A model for
practice in physical dysfunction, pp. 3-12.
Copyright © Elsevier 1996.)
Although originally described as a frame of reference for practice and educational design (AOTA,
1973, 1974), the OPM detailed the profession’s
domains of concern, focus, and areas of expertise
and has had a substantial and enduring influence on
practice (Turpin & Iwama, 2011), especially in physical rehabilitation. The Model of Human Occupation,
first published in 1985 (Kielhofner, 1985), was the
first occupational therapy model to appear after the
OPM, and although the OPM was particularly influenced by rehabilitation and focused on increasing
a person’s skills, the Model of Human Occupation
initially addressed a conceptual gap that existed
for practice areas in which clients had permanent
impairments and disability and for which rehabilitation was not an appropriate model. Building on a
growing awareness that a rehabilitation slant had
overly influenced the profession’s approach to occupational performance (thereby limiting the profession conceptually), a proliferation of occupational
therapy models occurred in the 1990s, all centered
on a more contextualized and broader notion of the
concept of occupational performance.
One occupational therapy model that was developed at that time with occupational performance
as its core concern was the CMOP (Canadian
Association of Occupational Therapists, 1997). In
its more recent iteration, published in Enabling
Occupation II: Advancing an Occupational Therapy
Vision for Health, Well-Being and Justice (Polatajko,
Townsend, & Craik, 2007; Polatajko et al., 2013), the
CMOP-E emphasizes the importance of engaging in
occupation, regardless of whether an individual can
perform it. For example, Townsend and Polatajko
(2007) told the story of a father and his son with a
severe disability who undertake marathons, triathlons, and iron man events together. The son engages
in (rather than performing) the occupation as he is
towed and pushed by the father.
Within the CMOP-E, the person is conceived of as
an occupational being embedded in a broader context (Figure 3-2). People can influence their physical and mental health and their physical and social
environment through participation in purposeful
activity or occupation. They are “portrayed as having three performance components [the language of
the OPM]—cognitive, affective, and physical—with
spirituality at the core” (Polatajko et al., 2013, p.
23). Moving away from the individual focus of the
OPM, the CMOP-E, a client-centered model, conceptualized the client in six ways: individuals, families,
group, communities, organization, and populations.
From the perspective of the CMOP-E, the aim of
occupational therapy is to enable any or all of the
following through occupation: people’s engagement
in everyday life, people’s occupational performance,
and a just society in which all people are able to participate. Occupation is conceptualized as a bridge
that links the person and environment. It is through
their action that people connect with their environments. Occupation is important and has therapeutic
value because it affects well-being, structures time
and life more generally, and brings together individual and cultural aspects of the creation of meaning.
48
Chapter 3
Figure
3-2.
CMOP-E.
(Reprinted with permission from Polatajko, H. J.,
Townsend, E. A., & Craik, J.
[2007]. Canadian Model of
Occupational Performance
and Engagement. In E. A.
Townsend & H. J. Polatajko
[Eds.], Enabling occupation II:
Advancing an occupational
therapy vision for health, wellbeing & justice through occupation [2nd ed., pp. 13-36].
Ottawa, Canada: Canadian
Association of Occupational
Therapists.)
Although the model indicates that occupation can
be categorized in a variety of ways (depending on
its meaning and purpose for specific clients), it uses
the three categories of self-care, productivity, and
leisure (the OPM categories). It also emphasizes that
occupational performance and engagement have a
temporal dimension in that they are organized into
patterns over days, weeks, years, and the whole of a
person’s life. The purpose of engaging in occupation
is conceptualized as health, well-being, and justice.
Using Trombly’s (1995) distinction, occupation is
understood as both ends and means. That is, being
able to perform and engage in occupation is the end
that occupational therapy aims to achieve, but occupation is also used as the means to achieve this aim.
Occupational performance and engagement are
promoted by identifying challenges to them at both
individual and societal levels and addressing these
challenges. Assessment and intervention planning
are closely linked in that assessment aims to identify challenges to the occupational performance and
participation that is meaningful to the client and
required in his or her roles, and intervention is targeted toward addressing those challenges. To come
to understand valued occupational performance
and engagement for a specific client, CMOP-E uses
a “who, what, when, where, and why” framework
(Polatajko et al., 2013). This framework guides occupational therapists to be client-centered in determining specifically who is doing what, when and where,
and why it is important to them (because they want
or need to). The Canadian Occupational Performance
Measure (COPM; Law et al., 1998, 2014) can be used
as an assessment tool to determine occupational
goals. Intervention could be focused on the person,
environment, and/or occupation.
The role of occupational therapists is to work collaboratively with clients, guided by the principles of
enablement and client-centered (or person-centered)
practice. The six enablement foundations outlined in
this model (Townsend et al., 2013) are as follows:
1. Choice, risk, and responsibility, in which occupational therapists “enable safe engagement in
just-right risk-taking”
2. Client participation
3. Visions of possibility, where both occupational therapists and their clients need to form
visions of what might be possible
4. Change, emphasizing that occupational therapy goes beyond simply restoring function and
preventing problems (the predominant focus
of rehabilitation) but promotes change that
facilitates the development or expansion of
occupational patterns, balance, and transitions
5. Justice, where occupational performance and
engagement are enabled by recognizing and
addressing systematic injustices that affect
people
6. Power sharing, emphasizing that occupational
therapists work with clients in a collaborative
and equal way
Intervention is underpinned by these six enablement foundations and uses the following 10 (alphabetically ordered) enablement skills: Adapt, Advocate,
Coach, Collaborate, Consult, Coordinate, Design/
Build, Educate, Engage, and Specialize. These enablement skills are outlined in the Canadian Model of
Client-Centered Enablement. Townsend et al. (2013)
also identified three categories of generic skills that
underpin enablement. These are:
Models of Occupational Therapy
1. Process skills: analyze, assess, critique, empathize, evaluate, examine, implement, intervene,
investigate, plan, reflect
2. Professional skills: comply with ethical and
moral codes, comply with professional regulatory requirements, document practice
3. Scholarship skills: use evidence, evaluate programs and services, generate and disseminate
knowledge, transfer knowledge
When describing the environment, Polatajko et al.
(2013) stated, “The model depicts the person embedded within the environment to indicate that each
individual lives within a unique environmental context—cultural, institutional, physical and social—
which affords occupational possibilities” (p. 26).
The environment is an important part of the “who,
what, when, where, and why” framework in that it
is not possible to separate the person/group and
what is being done from where and when it is being
done. Because the focus of the model is occupational
performance and engagement, the environment is
conceptualized as the context is what shapes this.
It influences choice, organization, performance, and
satisfaction but is not the focus of the model.
The outcomes of occupational therapy using this
model are occupational performance and engagement. To evaluate the achievement of these, occupational therapists would compare the outcomes of
intervention with the goals that were identified in
the COPM, as well reflect on the question of whether
occupational performance has been enabled (i.e., on
the process as well as the end result).
Addressing Mrs. Hume’s Home
Modification Needs Using the
CMOP-E
The focus of the therapist working with Mrs.
Hume using the CMOP-E would be on enabling
her performance of and engagement in meaningful
daily activities and roles through occupation. Mrs.
Hume would be viewed as someone who is actively
engaging in occupations, and attention would be
centered on occupations that are most meaningful
to Mrs. Hume and relevant to her life stage and living situation. The therapist would interview Mrs.
Hume and complete a COPM with her to identify her
self-perception of performance in day-to-day activities and the importance of these to her. From this,
the therapist would work with Mrs. Hume to identify
goals and then negotiate with her to work on the
goals related to the home environment. At the level
of the person, the therapist would observe Mrs.
49
Hume undertaking meaningful and purposeful activities and roles in context and evaluate the impact
of her condition (i.e., analyzing affective, cognitive, and physical performance components) on her
occupational performance and engagement. At the
level of the environment, the occupational therapist
would undertake a home evaluation and examine the
impact of physical, cultural, and social aspects of
the home (and the influence of the institutional environment on the home) on Mrs. Hume’s occupational
performance and engagement. The attention given
to various occupational categories such as self-care,
productivity, and leisure would vary depending on
reimbursement schedules and the priorities of the
service organization and Mrs. Hume. For example,
a home modification service would prioritize Mrs.
Hume’s self-care and productivity tasks related to
her remaining safe and independent within the home
and the immediate surroundings.
The therapist would work collaboratively with
Mrs. Hume to tailor interventions in light of her
unique situation and preferences. The home environment would be reviewed in terms of its ability to
support occupational performance and engagement.
Aspects of the physical environment, such as features of the building, furniture, fixtures, and fittings
that can no longer be managed, would be identified
and removed, replaced, or modified. Consideration
would also be given to other people in the environment and to how roles may need to be reassigned
or modified to assist Mrs. Hume in daily activities.
Family members would be educated about Mrs.
Hume’s condition so that they can support her by
undertaking more difficult activities. For example,
her daughter might help Mrs. Hume and her sister
prepare meals that could be frozen in smaller portions and then reheated in the microwave so that
Mrs. Hume does not have to manage heavy saucepans. Cultural aspects of the home and community,
such as customs and behavior standards, would be
acknowledged when evaluating activities and roles
and recommending changes. The occupational therapist may also encourage Mrs. Hume to write to the
local council requesting that the sidewalk in front of
her house en route to the local shop be repaired so
that she and her neighbors of similar age can safely
walk to get their daily supplies. At the completion of
the intervention process, in which Mrs. Hume might
also have been connected to community groups
and other services, appropriate home modifications would have been collaboratively identified and
undertaken that would promote her occupational
performance and engagement. Occupational performance and engagement are then evaluated by
returning to the COPM and ensuring that her initial
50
Chapter 3
concerns and goals have been addressed and further issues have not arisen. If the issues have not
been adequately addressed, the occupational therapist may revisit the process and refine the intervention further.
Implications of Using the CMOP-E
for Home Modifications
The CMOP-E offers occupational therapists a
vehicle for defining their unique scope of practice.
Much of the knowledge about body structures and
functions gained by the profession during its alignment with the rehabilitation model provided the
foundation for understanding and addressing function and skill development as it affects occupational
performance. However, the CMOP-E moves away
from a focus on body structures and functions and
presents enablement through occupation as the core
of occupational therapy. Conceptualizing occupation as the bridge linking person and environment
means that promoting occupational performance
and engagement drives any intervention targeting the person and/or environment. Occupational
therapists consider people’s physical, cognitive, and
affective capacities, as well as their spiritual core, in
the context of their everyday activities, tasks, and
roles (grouped into the areas of self-care, productivity, and leisure) and in relation to their developmental stage, culture, and environment. As people
are seen as embedded in an environmental context
that “affords occupational possibilities” (Polatajko
et al., 2013, p. 23), the environment is a powerful
resource for promoting occupational performance
and engagement.
The rich understanding of the environment as
having cultural, institutional, physical, and social
aspects means that, in home modification practice,
consideration of the environment is not limited to
the physical aspects of the home. Home modification would not be considered an end in itself but as
a means to promote occupational performance and
engagement. Concern for what people do drives consideration of how the environment could be modified to enable their occupational performance and
engagement. Because occupation has unique meanings and purposes in different people’s lives, home
modification practice cannot simply be a procedural
process of applying similar solutions. Instead, an
occupational therapist would work with each client
to understand his or her occupational patterns and
priorities and negotiate and problem solve with the
client to determine modifications that would facilitate these, making them easier, safer, and/or more
likely.
At times, therapists experience difficulty attending to or prioritizing occupational performance
issues because these issues may be perceived as
being outside the scope of the service or not recognized within reimbursement schedules. In these
situations, it is important that therapists remain
mindful of the clients’ priorities and target evaluation and interventions to address these, even if
performance of and engagement in valued activities are not being addressed directly. If a therapist
is primarily responsible for making modifications
to the home for a client like Mrs. Hume, it is very
important that these modifications be constructed
with the client’s occupational performance and roles
in mind. For example, if gardening were an important
occupation for Mrs. Hume, repairing the path to the
garden would be important to her safety. It is also
crucial that therapists see themselves as part of a
continuum of care and refer clients to therapists in
other services who have the focus and resources
to address the client’s specific concerns regarding occupational performance and engagement. For
example, if Mrs. Hume would benefit from raised garden beds and this is outside the remit of the home
modification service, referral to another agency
would be required. When occupational performance
and engagement are addressed in a holistic way, all
of the factors affecting performance can be identified and the full range of suitable interventions determined. Even if the therapist is not in a position to
provide the solutions, the client can be empowered
to investigate assistance from elsewhere or purchase
preferred solutions themselves, such as writing to
the local council. If therapists are addressing only
a defined part of occupational therapy’s scope of
concern, they need to ensure that clients understand
what it is they can and cannot attend to. This is particularly important when client priorities are in conflict with or extend beyond the service focus. In such
cases, clients should be redirected to services that
are better aligned to their specific needs. It is also
important that therapists work within the service
to advocate for policy and service delivery changes
that better reflect clients’ occupational performance
needs.
The main outcome measure used in the CMOP-E
is the COPM. This measure is used to identify client goals and priorities. Because it takes a holistic
approach to goal setting, it is likely to identify goals
that would be beyond the scope of many home
modification services, so it can be a very useful tool
for determining other services that would be valuable in helping the client to achieve those goals. It
would also be a valuable tool to use to evaluate the
effectiveness of the home modifications undertaken
in achieving the client’s goals.
Models of Occupational Therapy
51
Figure 3-3. The Person-Environment-Occupation-Performance Model. (Reprinted with permission from
Baum, C. M., Christiansen, C. H., & Bass, J. D. [2015]. The Person-Environment-Occupation-Performance
[PEOP] Model. In C. H. Christiansen, C. M. Baum, & J. D. Bass [Eds.], Occupational therapy: Performance, participation, and well-being [4th ed., pp. 47-55]. Thorofare, NJ: SLACK Incorporated.)
The strength of the CMOP-E is its emphasis
on client-centeredness and its broadening of the
concept of occupational performance to include
engagement. In contrast to the earlier OPM, it
emphasizes that a person’s occupational performance and engagement are contextualized within a
cultural, institutional, physical, and social environment. However, central to the model is the notion of
occupation as the bridge that connects person and
environment. This differs from ecological models in
which a transactive relationship exists among person, environment, and occupation.
ECOLOGICAL MODELS
In the 1990s, new occupational therapy models were developed that highlighted the importance of the context in which occupational performance occurs (Brown, 2014). Brown (2014) identified the following three ecological models: Ecology
of Human Performance (EHP; Dunn, Brown, &
McGuigan, 1994), Person-Environment-Occupation
(PEO; Law et al., 1996), and Person-Environment-
Occupation-Performance
(PEOP;
Baum
&
Christiansen, 2005; Baum, Christiansen, & Bass,
2015; Christiansen, 1991; Christiansen & Baum, 1997,
with this model changing substantially in each version), although PEOP also conceptualizes occupation
as a bridge (Figure 3-3). Referring to contemporary
occupational therapy models at that time (largely
influenced by the OPM), Dunn et al. (1994) stated,
“In theory and in practice, context (as an area of concern for occupational therapists) has not received
the same attention as performance components and
performance areas” (p. 595). The term ecological
refers to the interactions of organisms with each
other and their environment (“Ecological,” n.d.).
The ecological models in occupational therapy particularly emphasized that occupational performance
occurs in and is shaped by specific contexts. These
models were “built on social science theory, earlier occupational therapy models, and the disability
movement” (Brown, 2014, p. 495).
As with other occupational therapy models originally developed in the 1990s, ecological models consider occupational performance to be the primary
interest of occupational therapists (with the latest
52
Chapter 3
Figure 3-4. Person-EnvironmentOccupational Model. (Reprinted
with permission from Law, M.,
Cooper, B., Strong, S., Stewart, D.,
Rigby, P., & Letts. L. [1996]. The
person-environment-occupation
model: A transactive approach
to occupational performance.
Canadian Journal of Occupational
Therapy, 63, 9-23.)
version of PEOP identifying participation, performance, and well-being as the central concern; Baum
et al., 2015) and recognize the dynamic and reciprocal relationship among person, occupation, and
environment. Ecological models, particularly the
PEO, are founded on the notion of “goodness-of-fit”
(Brown, 2014, p. 495), where occupational performance is optimized by a close match between the following elements: the person’s skills and abilities and
the affordances and demands of the occupation and
environment (Figure 3-4). Because these elements
are intertwined, they are not dealt with separately
but as a whole. The various ecological models refer
to the whole in different ways. For example, in PEO,
an event is the unit of analysis (Law et al., 1996), in
which the focus is on certain people doing particular
things in specific places, at specific times. EHP uses
the term performance range to refer to the tasks that
are available to a specific person in a specific environment (Dunn et al., 1994). A change in any of the
elements will cause alteration to their fit, resulting
in changed occupational performance and participation (a change in the whole). Goodness-of-fit has
a temporal dimension, and the elements of person,
occupation, and environment will change over time
(e.g., at different times in the life course and from
moment to moment as people change what they are
doing and move in and out of different environments;
see Figure 3-4).
Ecological models build on the traditional occupational therapy concept of people as unique. Each
person is viewed holistically and is acknowledged
as bringing unique personal attributes, capacities,
and life experiences to the collaboration. However,
using the example of the PEO, ecological models
differ from occupation-based models such as the
CMOP-E in that, rather than being client-/personcentered, the person is only one of three elements
(person, environment, and occupation), the capacities, demands, and affordances of which must fit
well together to promote occupational performance.
From a transactional perspective, the person cannot
be considered separately from their environment
and, as Law et al. (1996) stated, “a person’s contexts
are continually shifting and as contexts change,
the behaviors necessary to accomplish a goal also
change” (p. 10).
Ecological models center on meeting goals for
occupational performance and focus on the principle of goodness-of-fit when a person performs
occupation in specific contexts. If any one or several
of these elements change, then goodness-of-fit will
alter. As people are constantly changing what they
are doing and where, goodness-of-fit is not static but
conceptualized as resulting from a dynamic process.
All elements interact reciprocally and continuously
across space and time to constrain or facilitate occupational performance (Brown, 2014).
Like all occupational therapy models, need
is defined in terms of a person’s specific concerns regarding occupation. Particular attention
is paid to identifying the nature and extent of
issues impeding the performance of occupations
the person needs and wants to do (usually determined by his or her roles and preferred occupations; Law et al., 1996). Ecological models consider
Models of Occupational Therapy
occupational performance breakdown as resulting
from poor person-environment-occupation fit (PEO
fit). Occupational therapists use both subjective
and objective methods to evaluate performance,
participation, and the PEO fit and to understand
the value and acceptability of the performance to
the person (Law et al., 1996). They examine PEO
fit using skilled observation of the whole event
(the person performing the occupation in the natural environment) and analyzing when, where, how,
and why the performance is breaking down. The
occupational performance difficulty might result
from a change in the person’s abilities, the way he
or she undertakes the occupation or the demands
of the environment, or some combination of these.
Specific assessments may be undertaken to gain
a more detailed understanding of any of the three
elements: the person’s capacity and how this might
be contributing to performance breakdown; examination of specific aspects of the environment; and
occupational and activity analysis, to determine
the demands of preferred and necessary occupation. However, assessments in ecological models do
not consider the elements separately, but together.
Therefore, examples of ecological assessment would
include observing people demonstrating how they
perform an occupation in their own homes; identifying through interview that someone experiences
a challenge when performing an occupation in one
environment while having no difficulty in a different environment; hearing a client report that since
acquiring an impairment, he or she is no longer able
to perform an occupation in the same way as previously in a familiar environment.
The role of the occupational therapist in ecological models is to promote occupational performance
by enhancing the PEO fit. These models encourage
occupational therapists to use a broad range of intervention strategies aimed at making changes in the
person, environment, and/or occupation (i.e., they
are likely to be used in combination). When seeking
to enhance the capacities of the person, they might
use established rehabilitation principles, education,
or tools to increase emotional well-being, such as
motivational interviewing. If their intervention targets the environment, specific strategies might, for
example, aim to change the various dimensions of
the home. Interventions may be used to alter the
demands of occupations such as grading and adapting and the provision of equipment. Dunn et al. (1994)
outlined the following five principles of intervention:
establish or restore an individual’s skills and abilities, alter or change the environment in which occupational performance is being undertaken, adapt
the contextual features or task demands, prevent
53
difficulties arising, and create “circumstances that
promote more adaptable or complex performance in
context” (Dunn et al., 1994, p. 604). However, Law et
al. (1996) cautioned that changes in any one of these
areas will have an impact on the others, but not in a
way that can be predicted. Therefore, occupational
therapists need to be alert to unanticipated consequences of their interventions.
In ecological models, the environment is one of
three elements that lie in a transactive relationship.
Drawing on theories of the environment from several disciplines, and also incorporating theories of
environment-behavior (to provide a richer description of the relationship among people and their
environments and occupations), ecological models
conceptualize environmental contexts broadly as
having cultural, temporal, social, socioeconomic,
societal and institutional, and physical (natural
and built environment) elements. Ecological models
conceptualize the environmental context as shaping and being shaped by people (Turpin & Iwama,
2011). For example, the cultural environment shapes
what people think and how they see the world, and
this, in turn, shapes the cultural environment (often
reinforcing shared culture; however, some strategies
might specifically be employed to change attitudes).
At an individual level, although EHP presents people
as being surrounded by potential tasks, the environmental context will determine the specific performance range that is available to a person (often
strongly influenced by that person’s roles; Dunn et
al., 1994).
The expected outcome of ecological models is
that people will be able to perform the occupations
that they need and want to do because the PEO fit
has been enhanced. Evaluation measures that could
be used include comparisons between assessments
undertaken before and after intervention—goalbased assessments such as the COPM.
Addressing Mrs. Hume’s Home
Modification Needs Using an
Ecological Framework
In using an ecological model in the case of Mrs.
Hume, the occupational therapist first recognizes the
uniqueness of her experience of her condition; the
occupations and roles that are expected of and/or
preferred by her; and the environments in which she
lives, works, and recreates and considers how these
combine to affect her occupational performance
and participation. Mrs. Hume’s occupational performance is likely to vary throughout the day, from
one day to another, and into the future, depending
54
Chapter 3
on her capacities, the demands of her roles and
occupations, and how the various environmental
contexts constrain or enable performance and participation. The therapist will seek to optimize Mrs.
Hume’s occupational performance by enhancing the
congruence among her capacities and motivations,
her occupations and roles, and the environmental
contexts in which they occur. Using discussion and
observation, the therapist will identify the nature
and extent of occupational performance concerns in
collaboration with Mrs. Hume. He or she will obtain
an occupational history and profile and observe
and analyze performance using standardized performance, occupational, and environmental assessment tools. The occupational therapist will identify
Mrs. Hume’s occupational performance goals and,
together with her, evaluate the quality of her performance to determine its acceptability and to ensure
valued occupations are prioritized.
These models recognize Mrs. Hume’s life experience, values, interests, personal attributes, and
strengths and build on existing strategies and supports to develop interventions. With the notion of
the goodness-of-fit in mind, the therapist will explore
a range of alternative interventions with Mrs. Hume
that could result in enhanced occupational performance and participation. These may include developing skills, exploring alternative ways of undertaking tasks, and making changes to the environment. Collaboration with Mrs. Hume is undertaken
throughout so that a rich understanding of her life
underpins the work of extending her involvement in
occupations and roles and increasing her participation, where appropriate, in activities in the home
and community. The therapist will work closely with
Mrs. Hume to explore and evaluate various options
to ensure that they fit with her requirements, preferences, personal style, and the way tasks are
undertaken. In addition, the therapist will discuss
the intervention options with Mrs. Hume to ensure
that they will work within the cultural, socioeconomic, institutional, physical, and social aspects of
her home environment and community. Therapists
using these models are aware that any change to the
person, occupation, or environment is likely to affect
the other aspects in unanticipated ways. Hence, care
is taken to examine these possibilities prior to recommending them and then to monitor unexpected
outcomes following implementation. The occupational performance outcomes sought by Mrs. Hume
form the foundation for evaluation, using tools that
assess her satisfaction with her current performance
as well as more objective measures of performance
quality. In addition, measures of Mrs. Hume’s participation in the household, neighborhood, and wider
community would be used. The therapist might
encourage Mrs. Hume to write to her local council
requesting improved accessibility to and additional
seating in the shopping mall. Alternatively, the therapist might make representation to management of
the local mall or local business community to advocate for better access or additional seating for older
people and people with disabilities. The therapist
might also join community or industry groups to
advocate for more appropriate housing and better
access to community facilities and services for older
people and people with disabilities. People like Mrs.
Hume would benefit if these were characteristic of
their regular environmental contexts.
Implications of Using an Ecological
Model for Home Modifications
Ecological models acknowledge the complexity
and variability of occupational performance because
of the dynamic transaction between the person,
occupation, and environment. This closely reflects
the reality of practice and enables occupational
therapists to analyze and explain occupational performance in terms of the “goodness-of-fit” among
person, occupation, and environment, rather than
attributing problems to the individual. Ecological
models also recognize the uniqueness of each person—their abilities, the way they perform tasks, and
the personal nature of the home environment—and
allow occupational therapists to understand and tailor interventions to specific situations. They shift the
occupational therapists’ focus from evaluating the
detail of each of the elements separately to trying to
understand how they interact in the whole situation.
Ecological models empower occupational therapists to take a holistic view of the person in context,
attending carefully to what the person wants and
needs to do and the specific features on the environments in which they need to perform these occupations. The models encourage therapists to gain a
deeper understanding of each person’s perceptions
of performance issues in their specific environments
and to work with people to identify priorities, as
well as existing strengths and supports, that can
be used to promote occupational performance and
participation. Occupational therapists work collaboratively with people and acknowledge the experience and knowledge that each person brings to the
partnership.
An understanding of the inevitable variability
of occupational performance and participation (as
outcomes) ensures that therapists develop solutions
that are flexible enough to support performance
across the day, the week, and into the future. By
Models of Occupational Therapy
providing a range of alternative intervention options
aimed at enhancing PEO fit by one or several of following—improving the person’s capacity and skill,
finding another way to perform the activity, or modifying the environment—therapists provide choices
and assist individuals to build a repertoire of useful strategies to use in different situations. These
models enable occupational therapists to work with
individuals to deal with the complexity of the home
environment and to determine how interventions
might affect the cultural, socioeconomic, institutional, physical, and social aspects of the home
environment and the community. They also require
occupational therapists to look beyond just the
home environment and to ensure that performance
is supported in all of the environments in which
the person operates. With an understanding of the
complexity of the home environment and the uniqueness of each person, and knowledge that making a
change in any of the three elements will alter the
others, occupational therapists appreciate the need
for follow-up to address any unexpected outcomes
of interventions. The perceptions and experiences
of the person are central to evaluating the success
of the intervention, and the effectiveness of the solution is evaluated in terms of how well it reflects the
goals and wishes of the individual and fits the unique
PEO transaction. Finally, these models encourage
therapists and the profession to look beyond the
individual household and situation to examine how
services, systems, and policies can be mobilized
to further promote occupational engagement and
performance, encouraging therapists to become
involved in communities and systems to ensure all
members of the community can fully participate in
society (Brown, 2014).
The image of the difference between maps and
schedules when travelling is useful for considering
the potential difficulties of using ecological models.
Using this analogy, ecological models are more like
maps than schedules. They are particularly valuable
for taking an expanded, contextual view of occupational performance, but they might need to be combined with detailed assessment and intervention
methods when putting them into practice.
CULTURALLY SENSITIVE MODEL
In response to the general lack of cultural relevance of existing occupational therapy models to
the Japanese context, a group of Japanese occupational therapists led by Michael Iwama developed
the Kawa model (Iwama, 2006). They found that
existing occupational therapy models, all of which
55
had been developed in Western countries, were
based on a very different worldview from that of
Japanese culture. In particular, the focus on the individual and the notion of a centralized self had little
resonance with the collectivist culture of Japan. In
essence, the Kawa model is also an ecological model
but adds extra symbolism, which can be useful to
describe concepts of occupational therapy practice.
The concepts of occupation and occupational engagement can be difficult to describe, particularly in
other cultures where these terms are often confused
with activity and function; although similar concepts,
they do not reflect the full scope of occupational
therapy practice. The model was initially developed
to address the cultural relevance of occupational
therapy models for Japanese society; however, it
has found resonance in and been used with other
collectivist cultures (e.g., Australian Aboriginal and
Torres Strait Islander peoples) and with those from
individualist cultures as well.
The Kawa model uses the image of a river as a
symbolic representation of life (Figure 3-5A). Just
as a river flows from the mountains to the sea, a
person’s life energy “flows” from birth to death.
Water is used to represent this life energy, and the
flow of water represents life flow. In a river, the
flow of water is both shaped by the contours of the
landscape through which the river flows and shapes
that terrain. Thus, the river metaphor presents an
individual’s life as deeply contextualized, shaped by
and shaping the surroundings.
In this model, the view of the person is informed
by a collectivist rather than individualist viewpoint.
In a collectivist culture, belonging is the most important aspect of life, and being and doing flow from
this. This is in stark contrast to many occupational
therapy models that prioritize doing, conceptualizing humans as occupational beings. The Kawa
model emphasizes the interconnectedness of people
and how their occupations are affected by this. As
Iwama (2006) explained, “one’s own or one’s group’s
occupations are interwoven and connected to the
occupation of others.”
The main focus of the model is promoting sukima,
a Japanese word referring to the spaces between
obstructions. Iwama (2006) refers to this as “where
life energy still flows: the promise of occupational
therapy” (p. 151). The strengths-based nature of
the Kawa model is evident in its central concern.
By focusing on the spaces, occupational therapists
can build upon what is working for people in their
particular contexts and work toward enhancing
life flow for that person in that particular context.
Turpin (2017) outlined the six steps followed when
using this model:
56
Chapter 3
A
B
Figure 3-5. Kawa Model. (Reprinted with permission from Iwama, M. [2006]. The KAWA Model: Culturally relevant occupational
therapy. Philadelphia, PA: Elsevier Health Sciences.)
1. Determine the relevance of the model and, if
relevant, who should draw the river diagram
2. Clarify the context through discussion with the
person(s) who draws the river
3. Prioritize issues according to the person’s perspective
4. Assess the focal points for intervention
5. Undertake intervention
6. Evaluate using person-centered goals
Identifying current challenges facing the client is
undertaken through drawing or conceptualizing the
river. Although this will involve drawing the length of
the river (to that point in the person’s life), a transection of that person’s “river” enables the occupational
therapist to explore the current challenges the client
experiences (Figure 3-5B). In the transection, the
river elements and their relationships are presented
through the various objects in and characteristics of
the river. The Kawa model originally identified four
elements of the river: water, river walls and floor,
rocks, and driftwood (Iwama, 2006). To facilitate a
strengths-based approach, two additional elements
were later added: Orange Tang fish and sparkles.
The river walls and floor shape the course and flow
of the river, and objects in the river may obstruct or
aid water flow. Each element is described as follows:
Ô Water (Miso): Emphasizing the interconnectedness of people and their surroundings, life flow
is represented by water, a liquid. In a collectivist society such as Japan, the group rather
than the individual is often the primary focus.
However, regardless of whether the social context is collectivist or individual, the liquid
nature of water emphasizes that all people
live within a context that shapes their lives (a
liquid conforms to the shape of the container).
Iwama (2006) explained that, in Japan, some
of the meanings and functions of water are
“fluid, pure, spirit, filling, [and] cleansing and
renewing,” and he emphasized that the culturally specific understandings of the elements
are important to elicit because they “will have
significant bearing on the utility of this model
in one’s practice” (p. 144).
Ô The river walls and bottom (Kawa no sky-high
and Kawa no Zoko, respectively): These elements, plus water, together form the central
concern of the Kawa model. The river walls
and floor represent the environment. In a collectivist culture, the social environment is
emphasized, with particular attention paid to
the social group to which a person belongs. In
all cultures, the environments in which people
live shape their lives (their life flow). Using the
river metaphor, the sides and floor could be
wide and deep, allowing water to flow easily, or
they could be narrow and shallow, restricting
its flow.
Ô Rocks (Iwa—Japanese for large rocks and
crags): In the model, these refer to life circumstances that impede life flow and are perceived
by the person as “problematic and difficult to
remove” (Iwama, 2006, p. 147). These could
include conditions that have been present from
birth (e.g., congenital conditions) or that have
developed during a person’s life (e.g., acquired
conditions). As Iwama stated, “Some of these
rocks remain unremarkable until they butt
up against certain aspects of the social and
Models of Occupational Therapy
physical environment” (p. 147) (e.g., a condition might not be problematic in some environments, but a person might be quite “disabled”
in other environments).
Ô Driftwood (Ryuboku): This represents personal
attributes and resources. Examples include a
person’s character, personality, values, and
skills, as well as material (e.g.. wealth, equipment) and immaterial (e.g.. friends and family)
assets. Driftwood can positively and negatively
affect circumstances and life flow in that, using
the river metaphor, they could enhance water
flow when they knock obstructions out of the
way or impede the flow of water when caught
on the river walls or other obstructions.
Ô Orange Tang and sparkles: These elements
have been added since the original book on
the Kawa model. The images of thriving fish
and sparkling, clean water are associated with
healthy environments. In the Kawa model,
these elements represent those aspects of a
person’s life that are going well. Their purpose
is to emphasize the strengths basis of this
model, rather than simply taking a deficit view.
When using the Kawa model, the role of the
occupational therapist is to promote life flow. This
could be done in a wide variety of ways. Taking a
strengths approach, occupational therapists would
aim to build on aspects of the person’s life where
life flow is occurring (sukima). From this starting
point, they might explore with the person ways that
obstacles (rocks) could be removed or altered to
increase life flow and how personal attributes and
resources (driftwood) could be strengthened or
used to address obstacles (e.g., driftwood can be
used to lever rocks). Occupational therapists might
work with the collective or the individual, as most
appropriate, and the first task is to determine who
should draw the river (as this may not be confined
to the person receiving services).
In the Kawa model, once a good understanding of
sukima and the river and its elements is obtained,
a broad range of intervention strategies could be
used. Intervention could be aimed at the context
(river walls and floor) so that it better supports
occupation. As context is understood very broadly
and often includes a collectivist culture, intervention
addressing the context is likely to include physical
components, interpersonal elements (especially family), and the expectations associated with the social
roles a person plays in society. Interventions could
also aim to remove or alter obstacles to occupation
and strengthen personal attributes and resources.
Examples might include taking on new social roles
57
that will provide further opportunities for occupation or relinquishing others that obstruct occupation, teaching skills that will enhance personal attributes, and facilitating the acquisition of resources
such as programs and equipment.
Evaluation of intervention is important. As with
the ecological models, because the Kawa model
takes a holistic perspective, intervention targeting
one aspect of the “river” will inevitably alter other
aspects of it. As Iwama stated, “When change is
introduced in any point in the context, all other
parts of the whole are affected and also subject to
change” (2006, p. 171). Therefore, occupational therapists need to be alert to unanticipated outcomes.
Addressing Mrs. Hume’s Home
Modification Needs Using a
Culturally Sensitive Framework
In the Kawa model, the central concern is promoting the person’s flow of life energy, which is conceptualized as shaped by and shaping the context in which
he or she lives. Consequently, the occupational therapist would seek to understand how well Mrs. Hume
feels her life energy is flowing within her broader life
context, which will particularly include those with
whom she shares her life. The focus would be on life
within and around the home and community, with
particular interest taken in Mrs. Hume’s roles and
related occupations and how these are interwoven
and connected to the roles and occupation of others. This contextual understanding, in which both
strengths and challenges are identified, would be
developed using the river drawing. The whole household might be involved in drawing a cross-section of
the river at the current time, identifying obstacles,
resources, and supports to life within the home. Mrs.
Hume and her sister, who live in the house, and her
daughter who visits regularly, could all contribute
to the river drawing by sitting down together and
talking about the various elements of the river. This
process allows them to think about life in the home
(the water—life flow) and what aspects of the house
facilitate or restrict their lives (river walls and floor).
The river metaphor facilitates discussion on the life
they want and the areas of the home that support it
(where the river is wide) or restrict it (narrowing of
the river). The conversation can explore life within
and around the home and how roles, occupations,
and dimensions of the environment contribute. Mrs.
Hume and her family might identify areas of the
home where they are well supported to enjoy their
valued roles and occupations, such as the lounge
room where they read, watch television, and take an
58
Chapter 3
interest in the activities in the neighborhood. The
bathroom and toilet might be identified as challenging because Mrs. Hume and her sister struggle with
the existing layout and floor surfaces, which create
uncertainty or restrict their enjoyment because they
are worried about slipping and being injured, which
would then prevent Mrs. Hume from continuing in
her volunteer roles in the community. Mrs. Hume’s
daughter might also highlight her growing anxiety
about the safety and well-being of her mother and
aunt when managing their medications and in dayto-day activities such as house maintenance. This
discussion of the river drawing aims to generate a
detailed understanding of each person’s viewpoint
so that it provides an accurate representation of the
household as a whole.
In the cross-section of the river, the challenging
and supportive elements of the home are identified
and represented using rocks and driftwood. Using
this strengths-based approach, evaluation and intervention are very closely intertwined because the
evaluation focuses on identifying what is working
well and what is not working (narrowing of the river),
and interventions aim to enhance what is working
well, thus expanding sukima (spaces where the
water flows) while addressing identified challenges.
During this process, the occupational therapist
listens carefully to discussions in order to understand life within the home and to understand the
family and their priorities, resources, and openness
to alternatives. By encouraging people to discuss
issues, the therapist develops a clear understanding
of each person’s perspective and works with them as
a group to ensure the drawing adequately represents
their experiences.
In developing the drawing, Mrs. Hume’s concerns
about using the bathroom are raised by the group.
Her reduced balance and agility are represented
as rocks and the wet, slippery tiles are shown as
narrowed river walls. The interaction between Mrs.
Hume’s balance and mobility and the bathroom
environment creates a high-risk situation, which
may be addressed by changing the environment to
reduce the risk and increase her ability to safely
and confidently take a shower. This increases life
flow by enhancing the spaces (sukima) between the
rocks and river walls. Mrs. Hume currently manages
her showering routine by being careful (driftwood)
as she uses existing structures such as the shower
screen and taps for support and always ensures her
sister is at home when she is in the shower. Mrs.
Hume’s late husband was a builder and, although she
is open to suggested modifications, she is sensitive
to making changes to the house he built (driftwood).
The daughter who lives nearby is very supportive
and has the capacity to house Mrs. Hume and her
sister (driftwood) while the modifications are being
made to the bathroom. Mrs. Hume and her sister
are both resourceful people (driftwood) and willing
to actively explore alternative strategies, the use of
equipment, or other resources in the environment
with the occupational therapist. Mrs. Hume has
savings that she is happy to invest in making the
modification suit her preferences. Her family is able
to contribute financially.
In addition to the drawing and associated discussion, the occupational therapist uses observation
and evaluation tools to examine occupational performance in various areas of the home to quantify
the magnitude of issues and ascertain their quality
and nature. For example, the therapist might ask
Mrs. Hume to demonstrate her showering routine to
identify tasks within the activity where her safety
is at risk to then discuss where further supports
could address these risks and enhance her showering experience. The therapist then presents a
range of recommendations that address observed
problems while building on strengths. Because Mrs.
Hume already uses structures in the bathroom to
keep herself safe while showering, the therapist can
capitalize on this and introduce safer structures into
the bathroom, such as well-placed grab bars, where
she is currently seeking support. However, because
the shower screen cannot support a grab bar, the
therapist would suggest reversing the direction of
the shower door opening so that a grab bar can
be attached to the wall to provide support as Mrs.
Hume or her sister step over the hob. The occupational therapist would discuss the implications of
this potential change for both Mrs. Hume and her
sister to ensure that any changes would increase the
sukima for everyone in the household.
The drawing and subsequent discussions would
be undertaken in the home, around a table, with all
relevant people present. The conversation would
acknowledge the social aspects of the environment
and the roles each person plays in the household,
family, and community. The interpersonal relationships are privileged in the discussion, allowing
everyone to contribute to the creation of solutions.
The physical environment is modified to reduce
barriers and promote occupation according to the
solutions that were chosen. The outcomes of a home
modification would be examined in terms of how it
contributes to the life flow for Mrs. Hume and her
sister. A new river drawing following the modification could be compared with the initial drawing to
discuss the extent to which changes increased life
flow and enhance roles and occupation and whether
any changes have occurred that may have narrowed
Models of Occupational Therapy
the river unexpectedly. These would be addressed
by revisiting the collaborative process previously
outlined.
Implications of Using a Culturally
Sensitive Approach to Home
Modifications
The Kawa model is essentially an ecological model
that is culturally sensitive, seeing people within
their context. Although it was originally designed to
work with people from a collectivist culture, it also
provides a transformative framework for working
with households undertaking home modifications
in individualist cultures. It recognizes the pervasive impacts of any changes to home on the whole
household. The home is a collective of people who
are intertwined financially, socially, physically, and
through the rhythms of daily occupations, as well as
past experiences and future aspirations.
The relevance of drawing a river to home modification practice may not immediately be clear to some
occupational therapists and clients because the
expectations would be for the therapist to provide
solutions rather than engage in a collaborative process. However, drawing the river provides an opportunity for all members of the household to contribute
to the conversation about life within the home. It
shifts the focus from identifying problems for an
identified individual and implementing specific interventions to considering how the household works as
a whole and how best to support a rich and healthy
home life. Although this process might appear to
be more time consuming, it allows the occupational
therapist to develop a richer and more comprehensive understanding of the home life, which may save
time negotiating options that are unacceptable to
the people in the household because the context of
the home was not well enough understood. It also
increases the likelihood that all people in the household have a vested interest in the solutions that are
developed.
This visual tool allows the client to engage in a
collaborative, creative process and to own and control the process and discussion because he or she
is doing the drawing rather than being the recipient
of a litany of targeted questions from the occupational therapist. The metaphor of the river allows
the household to identify issues to address without
being constrained by a professional lens. This is
particularly useful when working with families who
have children with a disability. For example, a family
might want their daughter with a disability to have
the experience of being involved in preparing the
59
family dinner. This issue might not have been raised
if the therapist’s protocol was driving the encounter.
Working with families using the Kawa model ensures
interventions are appropriate to the rich ecosystem
of the household and the lives people want, rather
than being focused on the needs of a particular individual. Being a strengths-based model, it recognizes
and builds on what is working well and what people
want to achieve rather than defining and addressing
problems.
The potential difficulty in using the Kawa model
is that it is based on a very different worldview than
most other occupational therapy models and is thus
less familiar for Western occupational therapists.
Although it can be used as “simply another personenvironment-occupation model,” when occupational
therapists take on this different worldview, the true
transformative nature of this model can be realized.
However, the task of seeing the world from a different vantage point is a difficult one that requires deep
reflection on one’s own culture and way of seeing the
world.
CONCLUSION
Occupational therapists use models, either implicitly or explicitly, to define their scope of concern and
role, identify and understand issues or problems,
determine appropriate evaluation and intervention
strategies, and evaluate outcomes. Conceptual models provide overview concepts and describe the
relationships between the identified elements, and
procedural models specify a procedure for attending to issues and elements. Therapists need both
conceptual and procedural models to operate effectively because practice requires therapists to have
an understanding of all of the elements of concern
and their interactions, as well as a plan of action.
However, therapists need to be aware of the models they draw on in practice and ensure that their
actions echo their stated focus and goals. Each
model presented in this chapter conceptualizes the
person, occupational performance, environment,
and interaction between these in different ways, all
of which have an impact on how occupational therapists engage with issues and implement environmental interventions.
The rehabilitation model provides therapists
with knowledge of body structures and functions
and allows them to reduce the amount of residual
impairment resulting from an injury or health condition and to promote function and independence.
However, without a deeper understanding of the
particular difficulties an individual is experiencing
60
Chapter 3
in daily activities, interventions are not tailored to
the specific needs of the individual and may result
in changes that are ineffective or unacceptable in the
home environment.
In shifting the focus of therapy to occupational
performance and engagement, the CMOP-E guides
occupational therapists in a client-/person-centered
approach to enabling occupation. The goal of an
occupational therapist using this model is to enable
people’s engagement in everyday life, their occupational performance, and a just society in which all
people are able to participate. People’s occupational
performance and engagement are conceptualized as
embedded within a cultural, institutional, physical,
and social environment.
The ecological models, with their understanding
of the dynamic transaction among person, occupation, and environment, provide a holistic framework
for addressing the complexities that individuals
encounter when undertaking everyday activities
in the home and community. They recognize the
continual change that occurs because people continuously change their occupations and the environments in which they are performed. Recognition of
the environment as a means of limiting and creating occupational performance opportunities also
enables therapists to actively use the environment
to promote participation within the home and community. Both ecological models and the CMOP-E
encourage therapists to move beyond working with
individuals to becoming agents of change within the
community, thus ensuring equitable participation
for all.
The Kawa model is an ecological model that differs from most occupational therapy models in its
symbolism and worldview. Based on a collectivist
worldview, it encourages occupational therapists
to consider the interconnectedness of their clients’
occupations with those of others in their lives.
Models provide a framework for thinking and clinical decision making and a structure that ensures
systematic and comprehensive practice. When therapists are aware of the concepts shaping their practice, they are well placed to reflect on their practice
and articulate their unique contribution to stakeholders. Selection of evaluation and intervention
strategies is also thoughtful and well informed, and
the goal and outcomes of interventions are clearly
defined. Occupational therapy has a rich history
of describing and refining the models that shape
practice. It is important that these continue to be
thoughtfully applied to achieve good home medication outcomes for clients.
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“independence”: Perspectives of occupational therapists.
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Townsend, E. A., Beagan, B., Kumas-Tan, Z., Versnel, J., Iwama,
M., Landry, J., . . . Brown, J. (2013). Enabling: Occupational
therapy’s core competency. In E. A. Townsend & H. J. Polatajko
(Eds.), Enabling occupation II: Advancing an occupational therapy vision for health, well-being & justice through occupation
(2nd ed., pp. 87-134). Ottawa, ON: Canadian Association of
Occupational Therapists.
Townsend, E. A., & Polatajko, H. J. (Eds.). (2007). Enabling occupation II: Advancing an occupational therapy vision for health,
well-being & justice through occupation. Ottawa, ON: Canadian
Association of Occupational Therapists.
Trombly, C. A. (1995). Occupation: Purposefulness and meaningfulness as therapeutic mechanisms. American Journal of
Occupational Therapy, 49(10), 960-972.
Turpin, M. (2017). Occupational therapy practice models. In M.
Curtin, M. Egan, & J. Adams (Eds.), Occupational therapy for
people experiencing illness, injury or impairment: Promoting
occupation and participation (7th ed., pp. 115-133). New York:
Elsevier.
Turpin, M & Iwama, M. (2011). Using occupational therapy models
in practice: A fieldguide. Edinburg, UK: Churchill Livingstone,
Elsevier.
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Buffalo General Hospital, State University of New York.
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function, disability and health. Geneva, Switzerland: Author.
4
Legislation,
Regulations, Codes,
and Standards Influencing
Home Modification Practice
Elizabeth Ainsworth, MOccThy, Grad Cert Health Sci;
Desleigh de Jonge, MPhil (OccThy), Grad Cert Soc Sci; and Jon Sanford, MArch, BS
This chapter provides an overview of the worldwide range of legislation and guidelines relevant
to promoting the rights of people with a disability
through access to the built environment. Human
rights conventions and disability discrimination
legislation have shaped community values, design
and construction practice, and service delivery to
ensure that older people and people with a disability are afforded equitable access to goods, services,
and the built environment within the community.
In particular, building regulations, building codes,
and access standards that incorporate access and
mobility requirements have sought to address discrimination that might occur because of barriers
in public facilities and spaces. Although legislation
and guidelines have focused primarily on public
facilities, they are not without impact on housing.
Legislation and guidelines relating to the design of
accessible housing continue to emerge in a range of
countries through the efforts of people concerned
about the lack of inclusive environments. With an
enhanced understanding of the relevance and application of individual rights and building legislation,
occupational therapists will be better equipped to
promote the inclusion of older people and people
with a disability into everyday home and community life and to empower them to claim their rightful
place in society.
CHAPTER OBJECTIVES
By the end of this chapter, the reader will be able
to:
Ô Describe the development of international
human rights conventions and the implications
for older people and people with a disability
- 63 -
Ô Discuss disability discrimination and building
legislation and their impact on the design of
public and private built environments
Ô Understand the relevance and application of
rights-based legislation and building legislation
to the design and modification of the home
environment
Ô Understand the application of the complaints
and remedial processes that are used in relation to rights-based legislation and building
legislation
Ainsworth, E., & de Jonge, D. An Occupational Therapist’s
Guide to Home Modification Practice, Second Edition (pp. 63-81).
© 2019 SLACK Incorporated.
64
Chapter 4
INTERNATIONAL FRAMEWORK
FOR THE CREATION OF INCLUSIVE
ENVIRONMENTS
Integrating people with a disability into the community and enabling them to live in homes they
can call their own requires an understanding of the
international convention on the rights of people
with a disability and the emergence of rights-based
legislation over time. Though people with a disability were once seen as being dependent on welfare,
social assistance, or charity, they are now regarded
primarily as citizens with equal rights and obligations. The following discussion briefly describes
recent changes in the definition and models of disability, how these have influenced the development
of legislation, and service delivery to people with a
disability.
Nations High Commissioner for Human Rights, 2006;
Swain, 2004).
As a result, the WHO (2001) has adopted a
social definition of disability. The new International
Classification of Functioning, Disability and Health
not only defines disability as the interaction of body
function and structure with contextual (i.e., environmental and personal) factors, but it has extended it
to include the activity and participation outcomes
that result from this interaction. The environment is
viewed as either a barrier or facilitator to activities
and participation in social roles (WHO, 2001). Simply
put, for an individual with an impairment (e.g., cannot ambulate), the typical home environment (e.g.,
stairs) can pose barriers to everyday activity (e.g.,
getting in and out of the house) and participation
in social roles (e.g., neighbor interaction), whereas
home modifications (e.g., ramp) can facilitate these
outcomes.
Definition of Disability
Importance of Social Models of
Disability
The definition of disability has changed significantly in recent decades. Prior to the end of the
20th century, disability was defined using the medical model that attributed disability to health conditions. Disability was seen as a problem within
the person—a result of an individual’s physical or
mental limitations. A traditional definition of disability, widely promulgated by the World Health
Organization (WHO), described disability as “any
restriction or inability resulting from a disturbance
or loss of bodily or mental function associated with
disease, disorder, injury, or trauma, or other healthrelated state” (WHO, 1980, p. 143).
In the last decade of the 20th century, a number
of new models of disability began to emerge based
on Nagi’s work (1965, 1976) that defined disability as
the outcome of an interaction between impairment
and environmental factors (Institute of Medicine,
1991, 1997; National Center for Medical Rehabilitation
Research, 1993). Social models of disability emerged
that differed slightly from the medical model regarding the relationship among medical conditions,
impairments, functional limitations, and the effects
of the interaction of the person with the environment. Generally, these models agreed that disability
was a function of the interaction of the person with
the environment (Brandt & Pope, 1997). Social models of disability continued to develop and evolve
as people with a disability, their advocates, and
organizations supporting them sought to use these
to stimulate change in society (Office of the United
Social models of disability have encouraged a
shift in focus from flaws or deficits in the individual
(as described in the medical model or individual
model of disability) to activity restrictions or barriers created by a society that excludes people from
participating in everyday life in the community
(Harrison & Davis, 2001; Oliver, 1990, 1996). These
models describe disability as a complex phenomenon created, in part, by features of the physical,
economic, and political environment and not simply
a manifestation of a person’s impairment (Australian
Institute of Health and Welfare, 2003; Dickson, 2007;
Harrison & Davis, 2001; Samaha, 2007). The environment is seen to facilitate participation that enables
the fulfillment of roles appropriate to age, gender,
and social and cultural identity. Alternatively, it can
contribute to isolation, limiting achievement of daily
activities and restricting participation in social, cultural, and community activities (WHO, 2001).
The social models of disability provide frameworks for the formulation of appropriate recommendations to create reasonable and necessary environments that provide appropriate access for people
with a disability (Kornblau, Shamberg, & Kein, 2000).
It challenges occupational therapists to reconsider
their individualistic and medical approaches to
occupational performance problems and encourages them to identify and eliminate social and environmental barriers to performance and participation
(Whalley Hammell, 2001).
Legislation, Regulations, Codes, and Standards Influencing Home Modification Practice
Though social models of disability have facilitated
a shift from focusing on individual deficits to examining disabling environments and practices, they are
under increasing scrutiny. Like the medical model
and other theorizations of disability, these models
by no means provide a comprehensive description
of the experience of disability and are considered
reductionist in nature (Imrie, 1996). In particular,
social models have a tendency to ignore how impairment, in and of itself, has the potential to debilitate,
regardless of the environmental and social conditions (Imrie & Hall, 2001a; Shakespeare & Watson,
2001).
Although it is undeniable that environments and
social practices can alienate and disable people,
addressing these issues alone might not eliminate
the difficulties people with impairments experience (Shakespeare & Watson, 2001). Further, environmental design and social manipulations cannot
always prevent the personal experience of physical
and intellectual restrictions (Imrie & Hall, 2001a).
It is therefore important to take appropriate action
to address impairment in conjunction with removing environmental barriers and disabling practices
(Shakespeare & Watson, 2001). Whatever model of
disability is used, it is critical that all of the dimensions of the person’s experiences are considered,
including those of a physical, psychological, cultural,
social, and political nature, rather than simplifying
disability and operating within a medical or social
model (Shakespeare & Erickson, 2000).
DISABILITY LEGISLATION
The social models of disability, with their recognition of the environment’s influence on the experience of disability, has influenced the development of
specific legislation and guidelines aimed at protecting the rights of people with a disability in a range of
countries. The creation of a variety of international
declarations, rules, or conventions and national legislative acts protects the human and civil rights of
people with a disability throughout the world (Hurst,
2004).
Human Rights Protections
Human rights are those rights that are inherent
in an individual’s humanity. They sit above humanmade laws and exist whether there are national laws
to uphold them or not (Hurst, 2004). The universal
establishment of human rights is regarded as the
single most important political development influencing social change.
65
The rights of people with a disability have been
the subject of much attention in the United Nations
(U.N.; Office of the United Nations High Commissioner
for Human Rights, 2006). Through the creation of
various declarations, rules, and conventions, people
with a disability are now recognized as legitimate
citizens in society. The first indicators of international concern regarding the rights of people with a
disability were described in the U.N. Declaration on
the Rights of Mentally Retarded Persons (1971) and in
the U.N. Declaration on the Rights of Disabled Persons
(1975). Although these declarations did not detail
the monitoring mechanisms or the reporting obligations of the international community, they served
as the framework for human rights protections for
people with a disability worldwide. As a result, they
are regarded as the most important milestones in
the development of equal rights for people with a
disability (Imrie & Hall, 2001a).
The 1975 U.N. Declaration on the Rights of Disabled
Persons clearly called for national and international
action to protect the rights of individuals with a disability. It specifically stated that
Disabled persons have the right to live with
their families or with their foster parents
and to participate in social, creative or recreation activities. No disabled person shall
be subjected, as far as his or her residence
is concerned, to differential treatment other
than that required by his or her condition
or by the improvement which he or she may
derive therefrom. If the stay of a disabled
person in a specialized establishment is
indispensable, the environment and living
conditions therein shall be as close as possible to those of the normal life of a person
of his or her age. (U.N., 1975)
In the following decades, the U.N., through
various activities, continued to promote human
rights for people with a disability. The U.N. General
Assembly proclaimed 1981 the International Year of
the Disabled. In 1982, the General Assembly adopted
the World Program of Action Concerning Disabled
Persons, which established a world strategy to promote equality and full participation by people with
a disability in social life and development. In 1983,
the U.N. declared the ensuing 10 years to be the U.N.
Decade of Disabled Persons (1983–1992).
Because of the experience gained during the
Decade of Disabled Persons, the U.N. adopted a resolution entitled Standard Rules on the Equalization of
Opportunities for People With Disabilities in 1993. The
purpose of the resolution was to ensure that people
with a disability could exercise the same rights and
have the same obligations as others (Degener &
66
Chapter 4
Quinn, 2000; Mooney Cotter, 2007). It established
broad principles to guide nation states in developing
domestic antidiscrimination and equal opportunities legislation (Imrie & Hall, 2001a).
Although the Standard Rules on the Equalization
of Opportunities for People With Disabilities are considered to be the key moral imperative for change
on a worldwide basis (Degener & Quinn, 2000), they
were, nonetheless, nonbinding. As a result, disability rights activists and scholars have pressed for
the adoption of a new worldwide convention on the
elimination of discrimination against people with
a disability (Degener & Quinn, 2000). In response,
the U.N. Convention on the Rights of Persons With
Disabilities and its Optional Protocol were adopted
on December 13, 2006, at the U.N. headquarters in
New York and were opened for signature and ratification on March 30, 2007. The convention is considered
the first comprehensive human rights treaty of the
21st century (U.N., 2008).
The convention marks a “paradigm shift” in attitudes and approaches to people with a disability, moving them from being viewed as “objects”
of charity requiring medical treatment and social
protection to “subjects” with rights, who are capable
of claiming those rights (U.N., 2008). Further, the
convention emphasizes that people with a disability
can make decisions about their lives based on their
free and informed consent, as well as being full and
active members of society (U.N., 2008). Unlike the
Declaration on the Rights of Mentally Retarded Persons
(U.N., 1971) and the Declaration on the Rights of
Disabled Persons (U.N., 1975), the convention boldly
sets out a plan of action for countries to enact laws
and take other measures to improve disability rights
and to eliminate legislation, customs, and practices
that discriminate against people with a disability.
The U.N. declarations have also highlighted the
rights of people with a disability to have access
to the physical environment. The move to incorporate accessibility requirements into the various
declarations, rules, and conventions is considered
one mechanism by which people’s citizenship can
become a tangible outcome. The most recent U.N.
Convention on the Rights of People With Disabilities
(2008) details specific requirements with respect
to accessibility to the built environment. However,
it does not describe what accessibility should look
like or how it should be created, leaving it up to the
various nations that sign and ratify the convention
to detail specifications and develop mechanisms
for implementation and monitoring compliance. As
a result, there continues to be a great deal of political diversity and complexity in providing appropriate access, conditioned by country-specific social,
institutional, and political attitudes and values
(Imrie & Hall, 2001a). Some countries have legislation in place to ensure there is appropriate access to
public buildings; however, the convention does not
stipulate how nations should meet their responsibilities in terms of access to adequate housing. Further
work is needed at an international level to ensure
that well-designed housing is available for people
with a disability (Imrie & Hall, 2001b). Nations might
use a range of strategies to facilitate the creation of
appropriate housing, including the following:
Ô Building publicly funded housing and accommodation programs
Ô Ensuring building regulation and certification
through national, state, or local government
programs
Ô Enforcing antidiscrimination laws
Ô Introducing industry incentives
Ô Providing education and awareness training
(Ozdowski, 2005)
Disability Discrimination
Legislation and Civil Rights
Although changes to the built environment go
some way to providing people with a disability
access to facilities and services in the community,
they cannot fully eradicate misconceptions and
disablist attitudes in society. Such values and structures are better influenced through the pursuit of
civil rights for people (Imrie, 1996). One of the basic
human rights is freedom from discrimination, and
antidiscrimination legislation ensures that this right,
through civil rights laws or others, such as social
welfare, constitutional, or criminal laws, can be
enforced (Hurst, 2004).
Historically, people with a disability have been
excluded from or marginalized in the community
through discrimination. Disability discrimination
means treating a person with a disability less favorably for a reason related to that person’s disability,
without justification (Hendricks, 1995; Williams &
Levy, 2006). To ameliorate disability discrimination,
many countries have enacted legislation to mandate
that people with a disability be afforded the right to
fully participate in all aspects of society. Although
many countries have some form of disability discrimination legislation, the enforcement method, strength,
and effectiveness of this legislation vary considerably (Gleeson, 2001). In an analysis of international
disability discrimination legislation, Degener and
Quinn (2000) identified that the scope of the terminology and definitions differs substantially between
Legislation, Regulations, Codes, and Standards Influencing Home Modification Practice
countries. They identified that some of the most
comprehensive disability discrimination laws exist
in Australia, Canada, Hong Kong, the Philippines,
the United Kingdom, and the United States. Their
analysis included employment, provision of goods
and services, and transport. Additional areas specified included housing (Canada and Australia), education (United States and Australia), land possession
(Australia), access to premises (Canada, United
Kingdom, and Australia), and telecommunications
(United States and Australia).
The strength of disability rights legislation can be
attributed to different forces in different countries.
In the United States, the empowerment and influence of disability advocacy groups, such as Vietnam
veterans returning from war championing the need
for change (Barnes, Mercer, & Shakespeare, 1999),
was instrumental in moving welfare reform toward
civil rights law (Degener & Quinn, 2000; Waddington
& Diller, 2007). In the United Kingdom, civil rights
laws focused less on individual rights and more on
the achievement of social-policy gains (Gleeson,
2001). Because there is no written constitution in
Britain, the rights-based advocacy model, Gleeson
points out, has not been adopted. Whereas the
widespread politicization of people with a disability
and an advocacy group approach has been used
successfully in the United States to bring about legislative change, other countries, such as the United
Kingdom where various disability groups have not
been as unified and effective in influencing change
(Imrie, 1996), have relied on charities to drive the
process (Gleeson, 2001). In contrast, Australia and
New Zealand have secured improved civil rights and
social structural change, largely through initiatives
in state-government policy regimes (Gleeson, 2001).
The United States was one of the first countries to
adopt antidiscrimination legislation and civil rights
laws, starting with scattered equality provisions in
various laws (Degener & Quinn, 2000). Legislation
within the United States began with general civil
rights legislation in 1964. This seminal piece of legislation did not specifically target people with a disability, but instead served as the basis for a series
of disability-specific laws that covered both the
U.S. federal government and the country as a whole
(Fletcher, 2004; Peterson, 1998). The push for civil
rights legislation in the United States continued with
the development of more comprehensive laws, such
as the Americans With Disabilities Act (ADA) in the
1990s. Table 4-1 outlines the history of the development of U.S. legislation, regulations, and standards.
The ADA (1990) represents not only the centerpiece
of U.S. civil rights legislation related to people with
a disability, it is also a landmark piece of legislation
67
throughout the world. The intent of this legislation
is to ensure that people with a disability experience
equal opportunity, full participation, independent
living, and economic self-sufficiency, and it is considerably more extensive in its coverage than other U.S.
legislation (Department of Employment, Education,
Training, and Youth Affairs, 1997). Not only does it
give people with a disability the same protection as
other groups, it also seeks to integrate people with
a disability into the social mainstream and to break
down barriers created by prejudice (Waddington &
Diller, 2007). The ADA requires planners to consider
access as being more than a technical or design issue
and to understand its role in social injustice (Imrie,
1996). As rights-based legislation, it has heightened
society’s awareness of the built environment and the
part it has played, and continues to play, in isolating
and alienating people with a disability (Imrie, 1996).
Further, it has increased the visibility of people with
a disability in society, provided them with legal and
often moral means of influence, and transformed
some aspects of service provision for people with a
disability (Imrie & Hall, 2001a).
TRANSLATING LEGISLATION
INTO REGULATIONS
In the United States, when Congress passes a
piece of legislation, it becomes a law. Laws dictating social policy alone, such as the ADA (1990),
are generally insufficient to achieve accessibility.
Consequently, building laws and state legislation
that allow states to enforce building codes (including
accessibility provisions) have also been promulgated
to protect the rights of individuals with a disability.
There are also design guidelines to assist developers to fulfill the requirements of these laws. These
guidelines then serve as the basis for nominating
the standards that detail the technical information.
Figure 4-1 illustrates the relationship between laws,
guidelines, and standards.
The ADA is a comprehensive but complex law and
is considered to have a “patchwork quilt” of regulations associated with it (Ostroff, 2001). For example,
the Architectural Barriers Act (ABA) of 1968 was
initially developed to ensure access to facilities
designed, built, altered, or leased with federal funds.
This law was one of the first efforts to ensure access
to the built environment; however, unlike the ADA, it
did not have its basis in equal rights.
Under the ABA and ADA, the Access Board
develops and maintains accessibility guidelines.
These guidelines specify minimum or baseline
68
Chapter 4
Table 4-1. Developments in U.S. Legislation, Standards, and Design Documentation
LEGISLATION
STANDARDS AND DESIGN DOCUMENTATION
1964 Civil Rights Act
1961 ANSI A117.1 Making Buildings Accessible
For and Usable by the Physically Handicapped
(American National Standards Institute [ANSI], 2003)—
Voluntary access standards unless adopted by state or
local governments
1966 30 states pass the accessibility legislation to use
A117.1
1968 National Commission on Architectural Barriers to
Rehabilitation of the Handicapped (NCABRH) report,
Design for All Americans, establishes groundwork for future
accessibility legislation
1965 Formation of the NCABRH (1967)
1968 ABA (Public Law 90-480)—Those buildings and
facilities designed, constructed, altered, or leased with
federal funds required to be fully accessible
1973 49 states pass accessibility legislation to use ANSI
A117.1
1973 Access Board created under Section 504 of the
Rehabilitation Act 1973
1973 Rehabilitation Act
1978 Rehabilitation Act amended—Authorizes the Access
Board to establish minimum accessibility guidelines under
the ABA and to ensure compliance with requirements
1988 Fair Housing Amendments Act (FHAA)—
Expands the coverage of the Civil Rights Act 1968 to
cover families with children and people with disabilities;
access required for multifamily dwellings consisting of four
or more units, both public and private
1980 ANSI A117.1 revision
1982 Minimum Guidelines and Requirements
for Accessible Design (MGRAD)—Access Board
issues minimum guidelines under the ABA that form the
basis for enforceable standards
1984 Uniform Federal Accessibility Standards
(UFAS)—Four federal agencies jointly adopt standards
to enforce the ABA, based on MGRAD, and cover newly
constructed or renovated buildings built with federal
funding, including public housing
1986 ANSI A117.1 revision
1990 ADA (Public Law 101-336)—Extends civil
rights protection to people with disabilities; prohibits
discrimination in the full and equal enjoyment of
goods, services, facilities, privileges, advantages, or
accommodations of any place of public accommodation
(Title III) and state or local government (Title II). New
building construction and alterations to be accessible,
publicly and privately funded. Access requirements
applicable to common areas for multiunit accommodation.
1991 ADA Accessibility Guidelines (ADAAG)—
Covers access in new construction and alterations to
places of public accommodation and commercial facilities
covered by the ADA; also applicable to state and local
government facilities. Guideline serves as the baseline of
standards used to enforce the ADA; the Access Board
issued supplements to ADAAG covering state and local
government facilities (1998), children’s environments (1998),
play areas (2000), and recreation facilities (2002).
1991 Fair Housing Accessibility Guidelines
(FHAG) (Housing and Urban Development)—Guides
design requirements for multifamily housing
1992 Council of American Building Officials
(CABO)/ANSI A117.1 revision
1998 CABO/ANSI A117.1 revision
2003 International Code Council/ANSI A117.1
revision
2004 ADA-ABA Guidelines—The Access Board
jointly updates its guidelines under the ADA and ABA
to make them more consistent. Enforcing agencies under
the ADA and ABA adopt new standards based on these
updated guidelines.
Legislation, Regulations, Codes, and Standards Influencing Home Modification Practice
design criteria for regulations and standards to
fulfill the requirements of these laws, but they are
not enforceable unless a recognized agency adopts
them as regulations. Prior to 2004, the ADA and
ABA had separate guidelines. For example, the
MGRAD (Architectural and Transportation Barriers
Compliance Board, 1981) was first issued in 1982 as
the accessibility guidelines for the ABA. Similarly, the
ADAAG (1991) was developed by the Access Board to
support civil rights legislation (ADA) by addressing accessibility to all public facilities, regardless
of whether they receive federal funding (Nishita,
Liebig, Pynoos, Perelman, & Spegal, 2007). These
were periodically revised and, in 2004, were combined to form a uniform set of guidelines—the ADAABA Accessibility Guidelines—to cover both acts and
to be more compatible with ANSI A117.1 (2003), the
model accessibility code that is referenced in most
U.S. building codes. By 2009, all federal agencies,
with the exception of the U.S. Department of Housing
and Urban Development (HUD), had adopted the
ADA-ABA Accessibility Guidelines as mandatory to
ensure building accessibility in the public and private sectors.
Guidelines developed to reinforce the ADA and
ABA serve as a baseline for the development of
standards. Standards provide the technical information required to make spaces or elements accessible. This includes detailing specifications, such as
dimensions, materials, and slope or gradient requirements (Bowen, 2009). In 1984, the UFAS (1988)
was developed to enforce the ABA and Section
504 of the Rehabilitation Act (1973) for buildings
constructed with federal funding, including public
housing. UFAS was the result of combining accessibility standards developed by four separate federal agencies to comply with the Architectural and
Transportation Barriers Compliance Board’s MGRAD
(1981). Similarly, in 1994, the ADA standards were
developed by the Department of Justice to enforce
the ADA legislation and to ensure equal access
in and out of commercial buildings and places of
accommodation. The ADA standards have their
basis in the ADAAG developed by the Access Board.
Over time, the Access Board has combined both
the ADA and ABA Guidelines into one unified set
of guidelines (ADA-ABA Accessibility Guidelines,
2004). By 2009, some of the federal agencies vested
with enforcing the ABA adopted the new ADAABA guidelines. However, by 2009, neither enforcing
authority for the ADA had adopted the new version
of the ADAAG as ADA Accessibility Standards. As a
result, the new guidelines are not mandatory unless
adopted by these authorities. Because federal laws
(ADA) and regulations take precedence over state
69
Figure 4-1. Hierarchy of enforceable regulations to support
legislation.
and local laws and regulations, state/local laws/
regulations have to meet the minimum requirements
of the federal laws, although they can specify higher
standards (Rogerson, 2005).
There is a complex array of legislation covering various building types in the United States.
For example, building works addressed by various
pieces of legislation include the following:
Ô Construction or alteration of state and local
government and commercial facilities (ADA)
Ô Access to buildings constructed, leased, or
funded by the federal government (ABA)
Ô Access to public spaces in multifamily housing
(ADA)
Ô Construction or renovation of public housing
(Rehabilitation Act)
Ô Construction or modifications to federally
funded, designed, leased, or altered accommodation (ADA)
Ô Construction and modifications to multifamily
housing through specific housing legislation
(FHAA)
Ô Construction and modification of federally
assisted single-family housing and townhouses,
(Eleanor Smith Inclusive Home Design Act—
revised 2013)
70
Chapter 4
Table 4-2. Types of Facilities Addressed by Various Laws, Guidelines, and Standards
LAW
GUIDELINES
ADA (civil law)
1991: ADAAG
1992, 1998,
2004: ADA-ABA 2003: ANSI
A117.1
Guidelines
Construction or alteration of facilities in both public (state
and local government facilities) and private (places of public
accommodation and commercial facilities) sectors, including
places of public accommodation and commercial, state, and
local government buildings and public spaces within multifamily
housing
ABA (building law)
1982: MGRAD
1988: UFAS
All buildings constructed by or on behalf of the United States
leased by the federal government or financed by federal dollars
UFAS
New construction or renovation to a building using assistance
from the federal government, including public housing
504 Rehabilitation
Act (civil law)
STANDARD TYPE OF FACILITIES
Fair Housing
Act (FHA) 1968
(building law)
FHAG (1991)
ANSI A117.1
Sale, rental, and financing of private and public housing as well
as the physical design of multifamily housing—four units of more
or as few as two attached units that are not owner occupied
FHAA 1988
(building law)
FHAAG (1991)
ANSI A117.1
Residential structures of four or more units. Newly constructed
multifamily dwelling units.
Visitability (selected
states)
Private, single-family residences
Each of these laws has associated guidelines and
standards that address design requirements of the
specific facilities covered by the legislation (Table 4-2).
IMPLEMENTING AND MONITORING
ACCESS REQUIREMENTS
There are various mechanisms for implementing and monitoring compliance with legislation and
building regulations. As discussed in the previous
section, the design of guidelines and standards
is fundamental to ensuring buildings and facilities allow equitable access. These standards and
guidelines assist designers, developers, and builders in the design and building of accessible facilities. Building on the requirement of Section 504 of
the 1973 Rehabilitation Act, the ADA requires that
government entities receiving federal funds ensure
access to all new facilities and develop plans to correct deficiencies in existing facilities. To promote
accessibility, there is training in ADA requirements,
design guidelines and standards, and technical assistance via toll-free hotlines and publications (Ostroff,
2001). To check compliance, builders can undertake
activities, including engaging experts to review
plans, changing contract documents with design and
construction firms to ensure proper responsibility,
and completing construction site inspections and
post-construction inspections.
In most countries, the two main ways authorities
can monitor compliance are through pre-construction approval and a post-construction complaintsbased process. Pre-construction approval requires
that plans be submitted to an authority for endorsement (the issuance of a building permit that allows
construction to take place) before building can
commence (Richard Duncan, personal communication, July 23, 2009). This ensures that the design
complies with local or state building codes (not
necessarily civil rights laws) prior to construction. A
post-construction complaints-based process, which
generally follows compliance with the provisions of
the civil rights laws and their guidelines, allows complaints about a facility’s inaccessibility to be filed
with a suitable authority once the problems have
been identified. Enforcing disability discrimination
law is often the task of public administrative agencies and the courts (Degener & Quinn, 2000), though
complaints and lawsuits can be brought by private
individuals, groups, and other private entities. Some
countries, such as Australia, have a national construction code that requires all new public facilities
and major renovations to comply with referenced
access standards. This code mandates that plans be
endorsed as complying with accessibility requirements prior to construction. Such a process ensures
that all public buildings meet essential accessibility requirements and that the design and building
industry is clear about their responsibility to provide accessibility. This requirement also reduces the
Legislation, Regulations, Codes, and Standards Influencing Home Modification Practice
likelihood of a post-construction complaint process
occurring relating to discrimination; however, it
does not preclude it. The disability discrimination
legislation is used to deal with post-construction–
based complaints.
Disability discrimination legislation takes precedence over, and provides a broader mandate than,
building codes and regulations. Further, lawsuits
involving accessibility issues are usually based on
human or civil rights legislation (Ringaert, 2003). A
building might be built according to a building code
and/or standard, but if it excludes a targeted user
or protected class of people, certain entities could
sue because human or civil rights legislation would
indicate that a person could not be discriminated
against in the built environment on the basis of that
person having a disability (Ringaert, 2003).
In the United States, there are no pre-construction
approval processes for ADA compliance; rather, the
ADA is enforced after construction when a complaint is filed. Individuals who believe they have
been discriminated against may file a complaint
with the relevant federal agency or federal court
(Disability Rights Education & Defense Fund, 2008).
Enforcement agencies encourage informal mediation and voluntary compliance (Disability Rights
Education & Defense Fund, 2008). Yee and Golden
(2007) describe enforcement of the law as playing
a large role in the ADA’s success in raising public
awareness of the rights of people with disabilities.
The Disability Rights Section of the Civil Rights
Division of the U.S. Department of Justice is given
the lead federal role in enforcing the legislation, and
they investigate complaints lodged by the public,
undertake periodic compliance reviews, and bring
civil enforcement action (Mooney Cotter, 2007; Yee &
Golden, 2007). However, the Department of Justice is
authorized to bring a lawsuit where there is a pattern
or practice of discrimination in violation of the legislation (Mooney Cotter, 2007). In enacting the ADA,
Congress encouraged the use of alternative means
of dispute resolution, including mediation, to resolve
disputes. If mediation is unsuccessful, the various
parties can pursue all legal remedies provided under
the legislation, including private lawsuits (Mooney
Cotter, 2007).
Under the provisions of the ADA, existing structures that have been built prior to the ADA’s enactment also need to have accessibility improvements
when possible. In the United States, barriers have
to be removed only when it is readily achievable or
structurally practicable. Readily achievable means
that the changes are easily accomplished and can
be carried out with little difficulty or expense.
Examples include the simple ramping of a few steps
71
or the installation of grab bars where only routine
reinforcement of the wall is required. In determining whether an action to make a public accommodation accessible would be readily achievable, the
overall size and cost of the proposed changes to
the development are considered. Full compliance is
considered structurally impracticable only in those
circumstances where the incorporation of accessibility features is not easily accomplished and able to be
carried out without much difficulty or expense.
In the United Kingdom, the Equality Act, a civil
law, came into force on October 1, 2010 (except in
Ireland, where the Disability Discrimination Act
[DDA, 1995] is still in place and enforcement monitored by the Equality Commission for Northern
Ireland). The Equality Act has two main purposes:
to harmonize discrimination law and to strengthen
the law to support progress on equality. The DDA
1995 has been combined with over 100 other pieces
of legislation into this one act that provides a legal
framework to protect the rights of individuals and
advance equality of opportunity for all people.
Technical guidance, rather than a strict compliance
document, is provided. This guidance is considered
to be a nonstatutory version of a code that provides
comprehensive legal interpretation of sections of
the act and the requirements of the legislation. As a
result, it allows the requirements of the legislation
to alter in line with changes in national best practice
guidelines with regard to disability.
The U.K. Equality and Human Rights Commission
(1995) has a role to eliminate discrimination against
people with a disability and to promote equality
of opportunity (Sawyer & Bright, 2007). Under the
legislation, Disability Committees have been established in England, Scotland, and Wales because of
the highly distinctive nature of disability equality
law. The Disability Committees have decision-making powers in relation to those matters that solely
concern disability, and the commission must seek
the advice of the committee on all matters that
relate to disability in a significant way. An Equality
Advisory and Support Service provides online advice
about discrimination and rights to people who have
experienced discrimination, including handling of
complaints. If complaints have not been resolved,
individuals may take the issue to the Government
Equalities Office for review. It has replaced the
helpline service previously provided by the Equality
and Human Rights Commission.
Prior to the introduction of the Equality Act
(2010) in England, Scotland, and Wales, the DDA
in the United Kingdom was considered by some to
be more progressive in some areas than the ADA;
it introduced a wide range of regulations to ensure
72
Chapter 4
accessibility and that reasonable adjustments are
made (Imrie & Hall, 2001b). New design and planning
benchmarks are emerging (Gooding, 1996; Imrie &
Hall, 2001b). Access auditing of public premises has
also increased over time, and businesses are questioning the implications of the DDA for their service
(Gooding, 1996; Imrie & Hall, 2001b).
In Australia, access to the built environment is
monitored through the DDA (1992) through a postconstruction complaints-based process overseen by
the Australian Human Rights Commission. The DDA
requires that action plans be developed by the operators or owners of the public premises and lodged
with the Australian Human Rights Commission to
ensure that complaints are not submitted postconstruction. The Australian DDA recognizes that
equitable access for people with disabilities could
cause unjustifiable hardship for the owner or operator of the premises. The DDA does not require that
access be provided in the built environment if it
would impose unjustifiable hardship on the person
who would have to provide the equitable access. The
Federal Court or Federal Magistrates Service determines what constitutes unjustifiable hardship. Issues
considered in the claims of unjustifiable hardship
can include cost to the proprietor; technical limits;
topographical restrictions; the positive and negative
effect on other people; safety, design, and construction issues; and the benefit for people with a disability. The Disability (Access to Premises—Buildings)
Standards 2010 (the Premises Standards) have been
created by the Australian Human Rights Commission
to ensure that dignified, equitable, cost-effective,
and reasonably achievable access to public buildings and the facilities and services within buildings
is provided for people with a disability, and to give
certainty to building certifiers, developers, and managers that, if the standards are complied with, they
cannot be subject to a successful complaint under
the DDA in relation to those matters covered by
the Premises Standards (Australian Human Rights
Commission, 2015). The Australian Human Rights
Commission handles complaints about discrimination and uses a process of conciliation. If issues
are unresolved, they may be taken to the Federal
Magistrates Court or the Federal Court of Australia.
The Canadian Charter of Rights and Freedoms,
with the federal and provincial human rights legislation, is a different approach to the complaintsbased human rights approach followed in Australia
and the United States (Department of Employment,
Education, Training, and Youth Affairs, 1997). The
Canadian Human Rights Act (1985) emphasizes the
need to accommodate people with a disability unless
doing so causes undue hardship (Mallory Hill &
Everton, 2001). Case law has shown that upholding
this accommodation is a right and not a privilege
(Mallory Hill & Everton, 2001). Undue hardship is
measured against health, safety, and cost (Mallory
Hill & Everton, 2001). The Canadian Human Rights
Commission is responsible for human rights issues
and their application at the federal level. Separate
provincial and territorial human rights commissions are responsible for enacting the provisions of
the Human Rights Code within each province and
municipality (Mallory Hill & Everton, 2001).
Private Housing Legislation
Similar legislative and regulatory mechanisms
exist in the residential sector, although there are
few accessibility regulations that cover residential facilities and even fewer that comprehensively
regulate the design and modification of private
housing, specifically for people who are older or
who have a disability (Hyde, Talbert, & Grayson,
1997). Nonetheless, there is a growing movement in
some countries to extend accessibility regulations to
private housing. A number of countries have adopted disability discrimination legislation, which has
proven useful in situations where complaints have
been made by people with a disability who have not
been able to access the common areas of multifamily complexes. Countries such as Canada, which has
specifically omitted residential design and construction from national legislation, have left residential
accessibility up to local jurisdictions (Clarke Scott,
Nowlan, & Gutman, 2001; Mallory Hill & Everton,
2001; Rogerson, 2005). The United States is one of the
few countries in the world with civil rights legislation that covers private (multifamily) housing (Starr,
2005). Further, the ABA and the Rehabilitation Act
(1973) require a small percentage (5%) of housing
constructed with public funds to have accessible
dwelling units, and these are generally made available only to people who are eligible for publicly
funded housing (Maisel, Smith, & Steinfeld, 2008).
Specifically, in the United States, the FHA, originally passed as Title VIII of the Civil Rights Act of
1964, prohibits discrimination in the sale, rental, and
financing of private and public housing, as well as
the physical design of newly constructed multifamily housing, based on race, color, religion, gender, or
national origin (FHA, 1968). Title VIII was amended in
1988 by the FHAA, which expanded coverage of the
act to prohibit discrimination based on disability or
family status. The FHAA significantly expanded the
scope of the original legislation and strengthened
its enforcement mechanisms to cover public and
private multifamily housing (accommodation with
Legislation, Regulations, Codes, and Standards Influencing Home Modification Practice
more than four units; FHAA, 1988). Consequently,
under this legislation, property owners are required
to allow a tenant with a disability to undertake modifications within certain guidelines to accommodate
his or her individual need (Newman & Mezrich,
1997). However, tenants would be required to pay
for the alterations, comply with the building codes,
and, if requested, return the property to its original
condition when they leave (Lawlor & Thomas, 2008).
To reinforce the FHAA (1998), the U.S. Department
of HUD released technical requirements for multifamily housing in 1991. The FHAG are designed
to help builders comply with accessibility requirements as required by the government (International
Code Council, 2007). It refers regularly to ANSI A117.1
(2003) and guides developments that may or may
not have elevators.
The FHAG cover newly constructed multifamily homes constructed by builders, private property owners, and publicly assisted landlords (Imrie,
2006). Exempt properties include newly constructed
townhouses or fewer than four housing unit complexes and properties constructed in locations with
unusual terrain or other site characteristics that
limit accessibility (Mooney Cotter, 2007; Newman &
Mezrich, 1997; Nishita et al., 2007).
Builders constructing four or more owner-occupied dwelling units in buildings with one elevator
or more have to make all units accessible or have
to ensure accessibility to ground-floor units only if
there is no elevator (Imrie, 2006; Newman & Mezrich,
1997). Accessible design required in newly constructed housing (rather than in existing housing) includes
accessible common-use areas (e.g., via at least one
accessible entrance, doors that are wide enough
for wheelchairs to pass through, and kitchens and
bathrooms that allow a person using a wheelchair to
maneuver). It also includes other adaptable features
within the housing (e.g., an accessible route to and
through the dwelling, light switches, thermostats,
and other controls in accessible locations) and reinforcement in bathroom walls for future installation
of grab rails (U.S. Department of Justice, 2005). The
owner of newly constructed buildings must be an
active participant in making the building accessible
and usable by people with a disability compared
with the more passive role played by owners of existing properties (Newman & Mezrich, 1997).
Under the FHAG, access to public spaces in multifamily housing (e.g., exterior spaces, elevators, corridors, and interior common spaces) is mandated by
the technical requirements for public spaces in the
ADA-ABA Accessibility Guidelines. If a facility does
not comply with these requirements, residents with
disabilities can request reasonable modifications to
73
common interior or exterior areas at the property
owner’s expense (Newman & Mezrich, 1997).
One goal of the FHAA (1988) is to facilitate home
modifications in rental housing (Steinfeld, Levine,
& Shea, 1998) by providing people with disabilities
the right to reasonable accommodation. This means
that a landlord cannot prevent a tenant from adding
home modifications to a housing unit to increase its
accessibility (National Association of Home Builders
Research Center, 2007), though these changes must
be negotiated. There is a requirement that tenants
pay for these modifications themselves and that
they use a licensed contractor to complete the work.
At the end of their tenancy, they must return the
area to its original condition, again at the cost of
the tenant who installed the original modifications
(National Association of Home Builders Research
Center; Steinfeld et al., 1998). However, modifications
might be made to the interior of the home that do
not have to be removed if they do not affect the next
tenant’s use of the apartment (Steinfeld et al., 1998).
The section of the bill that deals with retrofitting
existing multiunit dwellings calls for “reasonable
accommodation” for people with disabilities, but it
is vague on the responsibility of the owner to pay
for changes, even in the common areas (Pynoos &
Nishita, 2006, p. 284).
As previously indicated, federal U.S. law requires
access for people with mobility and other impairments to all new multifamily residences and to a
small percentage of single-family homes constructed
with public funds (Maisel et al., 2008). Consequently,
current housing policy in the United States does not
address the vast majority of single-family homes
(as well as duplexes, townhomes, and triplexes) in
which most people live (Maisel et al., 2008). As a
result, “visitability” legislation has been developed
and implemented in the United States over the past
two decades, most of it occurring at state and local
levels (Spegal & Liebig, 2003). The visitability movement seeks to increase the supply of housing that
people with disabilities can visit or live in for a short
term. Design features include the incorporation of a
zero-step entrance, wide doorways, and at least one
bathroom on the main floor of the home (Maisel et
al., 2008).
Visitability programs have also begun to spread
throughout the United States, using mandates, incentives, and voluntary-based codes to encourage visitable design to be adopted in new housing. To date,
visitability legislation has been created in at least
27 U.S. cities (Maisel et al., 2008). Little is known
about the outcomes of these programs because of
the following:
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Chapter 4
Ô Not all locations use the term visitability in their
enactments
Ô There is no pattern of organizations accountable for the oversight of the ordinances
Ô Agencies responsible for the implementation of
the approach are not specified
Ô There is no one method of keeping track of how
many homes have been built (Spegal & Liebig,
2003)
The extent to which visitability is adopted depends
on local municipalities “buying” into the idea and
ensuring it is included in local ordinances or building codes. Much of the approach is being adopted
unevenly, depending on the political stance of the
various states. Visitability is continuing to face opposition because of concerns about cost and consumer
perception (Kochera, 2002).
Because of the fragmented adoption of visitability
on the state and local level, the visitability movement has inspired the creation of the Inclusive Home
Design Act that was first introduced into the U.S.
Congress as a bill in 2003, 2005, 2007, and then as
the Eleanor Smith Inclusive Home Design Act in 2015
(now known as HR 4202). Although Congress has not
yet passed the bill, it has the potential to ensure that
single-family homes receiving assistance from the
federal government incorporate visitable features
(Maisel et al., 2008).
The U.S. Supreme Court Olmstead decision (1999)
has also affected accessible housing because it
requires states to administer services, programs,
and activities for people with disabilities in “integrated” settings (Maisel et al., 2008). The decision has
led to more homes being made accessible, with some
states using funding from federal grant programs for
home modifications for people moving from institutions into the community (Maisel et al., 2008).
Implementing and Monitoring
Access Requirements
The FHAA (1988) established administrative
enforcement mechanisms to enable the HUD attorneys to bring actions before administrative law
judges on behalf of people experiencing housing
discrimination. Complaints filed with HUD are investigated by the Office of Fair Housing and Equal
Opportunity (Mooney Cotter, 2007). The Department
of Justice can take over the role of the department in
seeking resolution on behalf of aggrieved people if it
proceeds as a civil action (Mooney Cotter, 2007). A
United States administrative law judge may preside
over the case unless any party to the charge elects
to have the case heard in federal district court (U.S.
Department of HUD, 2015).
Similar to disputes in the public sector, disability discrimination legislation also takes precedence
over building codes and regulations in residential
settings (Ringaert, 2003). Consequently, a building
constructed according to a building code and/or
standard may still result in a complaint or lawsuit if
a person is discriminated against in the built environment based on that person having a disability
(Ringaert, 2003).
EVALUATION
LEGISLATION
OF
AND
CURRENT
STANDARDS
The rights-based approach to access policy used
in the United States has also been identified as having limitations (Gooding, 1994; Higgins, 1992; Imrie,
1996; Young, 1990). First, this type of approach reinforces the individual conceptualization of disability,
emphasizing the problem as belonging to the individual rather than a problem being the norms embedded in society (Higgins, 1992; Imrie, 1996). Second,
it presumes that the current situation that works
for the majority is the ideal; therefore, it should be
available and acceptable to all (Higgins, 1992; Imrie,
1996). Third, it is underpinned by a form of legal
individualism that ignores or denies the structural
inequalities that perpetuate discrimination against
people’s disabilities (Imrie, 1996). The onus remains
with the “victim” to establish harm has been done
in each situation (Imrie, 1996; Young, 1990). Rights
legislation also attempts to provide equal protection
to distinctly unequal groups and does not recognize
the potential value of positive discrimination in
addressing structural disadvantages (Gooding, 1994;
Imrie, 1996). Although legislation can contain overt
discrimination, it cannot eradicate it fully (Doyle,
1995; Imrie & Hall, 2001a). Consequently, the political and economic power of people with disabilities
needs to be restored to enable them to influence
government and corporate attitudes and practice
(Imrie & Hall, 2001b).
There is a great deal of diversity and complexity
in the way discrimination and civil rights legislation
and building legislation regulations, codes, and standards have been developed, operationalized, and
monitored across the world. Consequently, international legislative frameworks have also had varying
meaningful impacts on design practice and people
with a disability. For example, the civil status of people with a disability is markedly different between
the United States and the United Kingdom. Despite
Legislation, Regulations, Codes, and Standards Influencing Home Modification Practice
this difference, there continues to be a struggle for
this group in both countries to gain strong and binding antidiscrimination legislation that influences service delivery and the design of the built environment
(Imrie, 1996). Access issues in the United States are
regarded as matters of social justice, a problem relating to a person’s civil liberties (Imrie, 1996). In the
United Kingdom, the government sees access as a
technical or compensatory matter that can be dealt
with through redistributive measures (Imrie, 1996),
and U.K. developers have noted that people with a
disability have limited financial impact on their services and are reticent to build in features that meet
their needs (Harrison & Davis, 2001).
Almost all of the countries and territories have not
yet made the access requirements of people with a
disability and older people an integral part of development plans relating to different features of the
built environment (U.N., 1995). There are separate
approaches to formulating access legislation distinct
from existing relevant laws, bylaws, codes, rules,
and regulations in countries and territories such
as China, the Islamic Republic of Iran, Hong Kong,
Japan, the Republic of Korea, and Vietnam (U.N.,
1995). In contrast, Australia, Malaysia, and Singapore
adopted an integrated approach in formulating their
respective access legislation by incorporating access
standards for people with a disability into relevant
existing building regulations (U.N., 1995).
Another issue is that various pieces of legislation do not address the issues of creating livable
and usable living spaces (Imrie & Hall, 2001b) that
provide inclusive communities. There is evidence
of failure to incorporate access considerations in
urban and rural development projects and a focus
on access to buildings rather than the overall development (Imrie, 2006). Although access legislation of
Malaysia and Singapore applies to all types of buildings, including domestic buildings, legal instruments
of other countries and territories tend to apply to
public buildings only (U.N., 1995).
The use and enforcement of access law worldwide
is inconsistent and uneven within and between regulatory authorities (Centre for Housing Research, 2007;
Mazumdar & Geis, 2001; Newman & Mezrich, 1997;
Switzer, 2001). There is a perception that there have
been inadequate staffing and budgetary resources at
various government levels to implement and enforce
the legislation (Hinton, 2003; Mazumdar & Geis,
2001). Further, there is evidence that there is a high
level of ignorance about how and when to use the
regulations, particularly among those people who
are in roles of enforcement (Barnes, 2007; Centre for
Housing Research, 2007; Steinfeld et al., 1998). For
example, confusion exists in relation to how building
75
regulations interface with disability discrimination
legislation, resulting in design responses that are
often limited or confused (Imrie & Hall, 2001a).
Builders and owners are required to have an understanding of how their buildings meet the broad civil
rights requirements of the law, and yet many have
never studied law or civil rights interpretations
(Salmen, 2001). There is a view that even when owners understand the law, they might not understand
their responsibilities (Steinfeld et al., 1998).
Ambiguities, exemptions, and get-out clauses
characterize access statutes, thus diminishing their
coverage and effectiveness (Barnes, 2007; Imrie
& Hall, 2001a; Milner & Madigan, 2001; Newman &
Mezrich, 1997). For example, the ADA has get-out
clauses such as “undue hardship,” “readily achievable,” and “unreasonable financial costs,” which can
be used to justify not making built environments
accessible (Imrie, 1996). This and other legislation
have stipulations on reasonable provision of access
for people with disabilities that are vague and open
to interpretation (i.e., there appears to be multiple
interpretations of the word reasonable, which is used
frequently in legislation in this area; Imrie & Hall,
2001a).
The complaint process relies on people with a disability contacting the relevant authorities. However,
they often do not understand the intent and application of the legislation, regulations, and standards
and experience a great deal of difficulty in navigating the complaints system. The complaints process
can often be protracted and poorly articulated or
promoted. At times, people with a disability do not
have the emotional energy to cope with the process
and can fear negative or inadequate responses to
their requests, making them feel even more disempowered (Frank, 2005; Newman & Mezrich, 1997).
Further, some legal systems, such as those in the
United States, are adversarial in nature, influencing
people’s perceptions of or reactions to the complaint
process (Mazumdar & Geis, 2001).
Finally, agencies and groups participating in
formulating access legislation have varied greatly
between countries (Nielsen & Ambrose, 1998; U.N.,
1995). Consequently, legislation has tended to form
without a comprehensive understanding of the needs
of all people with a disability (Milner & Madigan,
2001; U.N., 1995). There is an emphasis on adults in
wheelchairs and a focus on the medical conception
of disability that is abstract and generalized (Imrie &
Hall, 2001a). There is also a generalization of access
requirements across groups of people (Imrie & Hall,
2001a). Building regulations also fail to take account
of the diverse and changing needs of people with
disabilities (Imrie & Hall, 2001a). Attitudes toward
76
Chapter 4
people with disabilities are still being framed by the
concept of the “undeserving poor,” or buildings are
being designed to provide minimum standards of
access (Imrie, 2003). Architects have been described
as making accessibility a legal rather than moral
imperative (Mazumdar & Geis, 2001). Consequently,
attitudinal and architectural barriers continue to
exist that limit the participation of people with disabilities in society (Switzer, 2001).
Private Homes
To support disability rights, civil rights legislation
has included provisions for the removal of physical
barriers to activity and participation, as well as the
designation of authorities to enforce those accessibility requirements. As pointed out at the beginning
of this chapter, the jurisdiction for these regulations
is primarily public buildings and facilities. There are
few regulations that cover residential facilities and
even fewer that comprehensively regulate the design
and modification of private housing, specifically for
older people and people with a disability (Hyde et
al., 1997). Nonetheless, there is a growing movement
in some countries to extend accessibility regulations
to private housing. In some countries, in the absence
of specific legislation, the design guidelines and
standards produced for public buildings are often
used as a guide when modifying private homes.
As explained in the chapter on access standards
(Chapter 11), this can be problematic if property
developers, design and construction professionals,
and occupational therapists are not familiar with
the limitations associated with the use of these standards. This can include, for example, the potential
mismatch between the functional ability of the person and the responsiveness of the accessible design
to that person’s needs (Sanford & Megrew, 1999).
Worldwide, approaches to ensuring housing accessibility are continuing to develop. For example, in
Europe, housing accessibility has been secured by
three main strategies:
1. Mainstreaming, where all new dwellings must
meet accessibility standards (e.g., Denmark,
Sweden, Norway, the Netherlands)
2. Exclusive legislation, which is applied to only
certain categories of users such as wheelchair
users (e.g., United Kingdom, Austria, Germany,
Portugal, Luxembourg)
3. A progressive approach in which increasing
degrees of accessibility and adaptability are
stipulated for different building types and users
(e.g., Italy; Nielsen & Ambrose, 1998)
Although many countries have adopted various
requirements for new housing, such as the United
States, these requirements are typically intended for
new multifamily housing (Kochera, 2002). Countries
with multifamily accessibility policies include Italy,
the Netherlands, France, Spain, Greece, and Sweden
(Kochera, 2002). As an exception to this, since 2004,
London, England, has had a policy that requires
all new homes (including houses and flats of varying sizes in both the public and private sectors)
be built to the Lifetime Homes Standard, with 10%
built to wheelchair accessible standard. In Wales
and Northern Ireland, the Welsh Assembly and the
Northern Ireland Housing Executive require the
Lifetime Homes Standard in their funded developments. The Lifetime Homes Standard is generally higher than that required by Part M of the
Building Regulations (which deals with accessibility), although some elements of Part M are equal to
the Lifetime Homes requirements or need relatively
minor changes to comply (Lifetime Homes, 2015).
Although it is easy to provide incentives and
regulations for new stock, most older people and
people with long-term disabilities live in established
housing and cannot readily afford to purchase new
dwellings. The following are examples of countries
that have building regulations requiring accessibility
in private homes (Imrie, 2006):
Ô Norway: Building regulations require an accessible entry and external approach to the common entrance of a building that has more than
four dwellings and toilets in all new dwellings,
regardless of whether they are single-family
homes or multiunit developments.
Ô Sweden: Building regulations state that there
must be wheelchair access to all units in a
residential building of three stories or more,
including an accessible path of travel from the
pavement to the building entrance, accessible
thresholds, and the provision of a lift (there is
no requirement for this in single-family homes).
Ô Denmark: Building regulations stipulate that
single-family homes that are self-built have to
be constructed to minimum levels of accessibility, including having a no-step entrance.
Ô Australia, Willoughby Council, New South
Wales: New developments with more than nine
dwellings are to incorporate adaptable housing
design (AS4299); this is similar for multiunit
developments for Waverley and Ryde Councils
in New South Wales.
Ô Japan: All new housing, both public and private,
are to be built to universal design standards.
Legislation, Regulations, Codes, and Standards Influencing Home Modification Practice
The U.S. approach to accessible housing is poor
and underdeveloped. No single U.S. law or program
regulates comprehensively for the design and adaptation of housing specifically for older people and
people with a disability, although a patchwork of
federal programs and mechanisms supports the
implementation of home modifications (Hyde et
al., 1997; Milner & Madigan, 2001). Regulations and
design standards typically focus on the needs of
wheelchair users with little consideration for the
diverse needs of the population of older people and
people with a disability. Little research exists on
the changes in wheelchair size and shape and the
impact of the introduction of new technology to
improve the mobility of the equipment and comfort
of the user, let alone the needs of the broader population of people with a disability whose access needs
might differ significantly from the wheelchair user.
Inevitably, future adaptations to homes designed
specifically for wheelchair users are necessary to
ensure better accessibility within the home and to
cater to the needs of a broader range of people with
a disability (Imrie, 2006).
A progressive approach, with use of increasing degrees of universal, accessible, and adaptable
design for different building types and older people
and people with a disability, can ensure housing
accessibility. For example, Italy has various laws
and ministerial decrees rather than a building code
or building regulations. It stipulates three levels
of accessibility: accessible (access to a building,
including common areas, through the entry and use
spaces within the building safely and independently); visitable (access to the principle spaces within
buildings and to where there is at least one accessible toilet); and adaptable design (modification to
the built environment at little cost; Christophersen,
2001; D’Innocenzo & Morini, 2001). This progressive
approach has developed from the movement to integrate people with a disability into the community.
Details and technical prescriptions have been added
gradually to existing regulations over the years,
resulting in professionals needing to keep in mind
the design requirements of people with a disability
while developing solutions (D’Innocenzo & Morini,
2001). Initially, public buildings were introduced
to access regulations; that has now been extended
to include public residential buildings and neighborhoods (D’Innocenzo & Morini, 2001). Different
design approaches for different building types were
selected based on the needs and priorities of the
neighborhood. People’s varying differences have
been driving a “policy of differences” for design
practice rather than designing to suit the “average
man” (D’Innocenzo & Morini, 2001, p. 15.20). Though
77
there are gaps in the practice of this progressive
design approach in Italy, a strong societal belief that
every person has the right to access his or her own
house and external built environments has emerged
(D’Innocenzo & Morini, 2001).
Regulations, incentives, and information have
been the three mechanisms used to promote adaptable housing for people of all ages and abilities in
Europe (Nielsen & Ambrose, 1998). However, statutes in relation to providing accessible housing vary
in form and content and are stronger in social-housing schemes or where the government has significant influence over the construction process (Imrie,
2006). The legal basis for ensuring access to housing is generally ineffectual, with limited means of
enforcement (Imrie, 2006). Consequently, some view
nonlegislative means as the fastest way to improve
building practice (Nielsen & Ambrose, 1998). There
is a perception that regulations increase cost, stifle design creativity and innovation, and decrease
responsiveness to the market (Imrie, 2006). However,
although there is a clear demand for accessible housing, there has been a poor market response. Some
believe nonlegislative approaches such as voluntary
guidelines, branding of universal designs, and information campaigns to be the least successful strategies for encouraging the development of more accessible housing in communities (Centre for Housing
Research, 2007). The countries that have been most
successful in producing a market response, such as
the United States, Japan, and Norway, have systematically combined regulatory, incentive, and collaborative capacity building strategies (Centre for Housing
Research, 2007). Countries where populations have
been growing older faster have had regulations for
new housing in place for a considerable length of
time (Centre for Housing Research, 2007).
IMPLICATIONS FOR
OCCUPATIONAL THERAPISTS
Occupational therapy services will continue to be
in demand to provide home modification advice as
older people and people with a disability struggle
with built environments that require design improvements. Occupational therapists understand that
older people and people with a disability constitute
a diverse population that does not suit a “one-sizefits-all” design approach. They have an awareness of
the limitations of the access standards that are used
as the basis for public building and private home
design, and they have an important role in informing
builders and developers about the individual design
78
Chapter 4
needs of clients in relation to the person’s home
environment.
An understanding of human rights and building
legislation will equip occupational therapists with
knowledge and information that can be shared with
older people and people with disabilities who may
need to negotiate with builders and government
authorities about appropriate design solutions in the
public and private sectors. Therapists can encourage
and empower older people and people with a disability to advocate for their own needs and provide their
perspective on improvements needed during design
and planning processes. Occupational therapists
are also well suited to influencing the values and
perspectives of design and construction professionals and advocating for better-designed environments
within the community by educating these professionals about the diverse needs of older people and
people with a disability, discussing the implications
of designs, and challenging builders and designers to
build more creatively and to universal design goals
and principles. Therapists are also well placed to
contribute to the evaluation of the effectiveness of
various built environments and the impact of the
environment on occupational performance, health,
safety, independence, quality of life, and home and
community participation outcomes. They also hold
a professional responsibility to monitor and respond
to proposed legislative changes and to support calls
for improvements to legislation, guidelines, and
standards.
CONCLUSION
This chapter has provided an overview of the
worldwide range of legislation and guidelines relevant to promoting the rights of older people and
people with a disability through access to the built
environment. Information has been given on the
move from the medical model to social models of
disability, their advantages, and their limitations.
This chapter has described how human rights and
disability discrimination legislation has attempted
to shape community values, design and building
practice, and service delivery to ensure people with
a disability are afforded equitable access within the
community. Information has been provided on the
ADA as a landmark piece of legislation in the civil
rights struggle for people with a disability in the
United States. In some countries, such as the United
Kingdom, building regulations and standards that
incorporate access and mobility requirements have
sought to address discrimination that might occur
from barriers in public facilities and spaces. Very few
countries have required their legislation to include
mandatory accessible design of private homes.
This chapter has highlighted that the emergence
of home environments that do not further disable
people is far from being realized. Although disability
discrimination, civil rights, and building legislation
in various countries have influenced the design of
public buildings, they have not made private accessible housing available to everyone requiring it, nor
have they eliminated attitudinal barriers (Switzer,
2001). Current legislation around the world is not
likely to make a dramatic change to the housing
circumstances of older people and people with a
disability. Rather, significant action is required to
transform attitudes and value systems to positively
influence housing quality and design for diverse
populations (Imrie, 2006). Occupational therapists
are well qualified and experienced to make a valuable contribution to transforming these attitudes
and values. They can influence the values and perspective of design and construction professionals
as they work in collaboration to design a more comprehensive use of dwelling spaces by people with
diverse needs. In addition, they have a valuable role
to advocate for older people and people with a disability and to empower them to influence design and
construction practice in the community.
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The Home Modification
Process
5
Elizabeth Ainsworth, MOccThy, Grad Cert Health Sci
and Desleigh de Jonge, MPhil (OccThy), Grad Cert Soc Sci
This chapter describes the home modification
process as undertaken by occupational therapists.
Overall, the process involves screening and prioritizing referrals, evaluating occupational performance
in the home environment, planning and negotiating
interventions, and monitoring and evaluating outcomes. More specifically, occupational therapists
arrange appointments, visit clients, listen to clients’
stories of their experiences in the home, gather
information, evaluate occupational performance,
research interventions, negotiate and recommend
intervention options, seek technical advice, and
evaluate the effectiveness of the interventions in
relation to client outcomes. At each stage of the process, occupational therapists adopt a dynamic occupation-based and client-centered approach, which is
influenced by specific models of practice and guided
by professional reasoning. Such practice ensures
that the health and level of participation of each client is maintained or enhanced through engagement
in occupation or valued daily activities.
CHAPTER OBJECTIVES
By the end of this chapter, the reader will be able
to:
Ô Describe the process occupational therapists
use when undertaking a home modification
Ô Explain the contribution of the occupational
therapist, the client, and other stakeholders to
the home modification process
Ô Explain the complexity associated with the
minor modification process and the important
role of the occupational therapist in this area
of practice
INTRODUCTION
The home environment provides the context for
many roles and activities and is an important setting for occupational therapists to examine when
seeking to promote a person’s occupational performance (Siebert, Smallfield, & Stark, 2014; Stark,
2003). With careful planning, people can remain
in their own homes and continue to participate in
community life (Law & Baum, 2005). Occupational
therapists work with older people and people with
disabilities to promote their health, well-being, and
participation through engagement in everyday life
activities (occupations) for the purposes of enhancing or enabling participation in roles, habits, and
routines in the home and community (American
Occupational Therapy Association [AOTA], 2014). In
this work, therapists develop an understanding of
the interaction between the following:
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Ainsworth, E., & de Jonge, D. An Occupational Therapist’s
Guide to Home Modification Practice, Second Edition (pp. 83-110).
© 2019 SLACK Incorporated.
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Chapter 5
Ô The clients’ physical, sensory, cognitive, neurobehavioral, and psychological capacities
Ô Their physical, social, cultural, societal, personal, and temporal contexts
Ô The occupations, activities, tasks, and roles
that clients identify as important (AOTA, 2014;
Law & Baum, 2005)
Occupational therapists take a specific approach
to home modification practice that is guided by a
range of various models, the client-centered and
collaborative approach, and professional reasoning.
Of significance to the occupational therapy process
is the importance and meaning that clients assign
to their homes and the value associated with completing the home modification assessment in this
environment.
Recently, ecological or transactional models in
occupational therapy have recognized the dynamic
relationship between the person, their environment, and their occupations and regard occupational performance (the ability of a person to carry out
activities of daily life) as a result of the transaction
between the client, the activity, and the environment or context (AOTA, 2014; Brown, 2009). The
focus of home modifications intervention, using
these models, is to optimize occupational performance. Occupational therapists establish a picture
of a person’s occupational performance by creating
an occupational profile that is a summary of a client’s occupational history and experience, patterns
of daily living, interests, values, and needs (AOTA,
2014). Then, by observing how the client performs
activities relevant to desired occupations, the therapist evaluates occupational performance, taking
note of the effectiveness of performance and performance patterns (AOTA, 2014). The various ecological
transactional models that guide this process provide
the theoretical basis, or underlying concepts, that
guide evaluation and the selection of environmental
interventions for use to optimize occupational performance (Stark, 2003).
Occupational therapists use a client-centered and
collaborative approach to ensure that they develop a
deep appreciation of the client’s experience and how
each is managing the occupations of everyday life
in the home and community. A client-centered and
collaborative approach allows therapists to work in
partnership with clients throughout all stages of the
home modification process, including evaluation,
planning, and negotiating interventions, and monitoring and measuring the outcomes (Law, Baptiste, &
Mills, 1995). This approach honors the contributions
of both the client and the occupational therapist
(AOTA, 2014; Law, 1998). Clients bring their stories to
the process, identifying and sharing their concerns
and priorities, while therapists contribute their
knowledge of occupational performance and the
person-environment-occupation transaction (AOTA,
2014; Law, 1998).
Professional reasoning skills are used by therapists as they listen to clients and observe them
interacting with their environment to plan, direct,
perform, and reflect on the care of clients (Schell
& Schell, 2008). A framework of scientific, narrative, pragmatic, ethical, and interactive reasoning is
used during the home modification process to frame
issues and guide problem solving and decision making (Schell, 2014). This framework also guides therapists in selecting and negotiating interventions in
collaboration with the client (Crabtree, 1998; Schell,
2014).
Throughout the home modification process, therapists remain mindful that the home is a private
living space and that clients attach meaning to the
home, the spaces, and the objects within it (Aplin, de
Jonge, & Gustafsson, 2013). Interventions can have a
significant impact on the home environment, which
can influence clients’ acceptance and adjustment to
changes in the home (Aplin, de Jonge, & Gustafsson,
2015). Consulting with the client’s family, friends,
caregivers, or other relevant stakeholders can also
optimize collaboration, agreement with recommendations, and satisfaction and improve overall client
outcomes (Law, 1998). Consulting with these stakeholders is required when a client is not able to make
informed choices and decisions about their home
modifications.
To ensure that home modifications are tailored to
the specific needs of each client, the occupational
therapy evaluation is undertaken in the home where
the activities are customarily performed (Corcoran,
2005; Law, King, & Russell, 2005; Siebert, 2005;
Siebert et al., 2014). Interviewing and observing people in their home environment provide occupational
therapists with an opportunity to observe activities and interactions as they occur in that setting
rather than relying on reports about the situation
(Corcoran, 2005) or on evaluations undertaken in an
unfamiliar environment. Interviewing the client in
his or her own home also enhances the occupational
therapist’s understanding of the environmental context in which the client operates (Aplin et al., 2013;
Corcoran, 2005).
The Home Modification Process
INFLUENCES ON OCCUPATIONAL
THERAPY PRACTICE
Home modification practice varies across the
world in terms of the extent and types of services
provided. Differing funding and service priorities
mean that some communities have well-developed
home modification services, whereas others rely on
a patchwork of local resources to attend to people’s
specific needs. The legislative context and building regulations in different jurisdictions can also
affect which services are provided and how they are
delivered. In some regions, home modifications are
provided within health and home care services; in
other locations, these services are provided within
the housing and building sector.
Within services, the types and levels of occupational therapy services provided for people requiring home modifications depend on the following:
Ô The service delivery requirements of the
programs
Ô The source and level of funding available
Ô The range of intervention options supported by
the service
Furthermore, occupational therapists working in
a private practice might provide a specific range
of home modification services, depending on reimbursement schedules or the level of funding available for their time. Occupational therapists’ competence in home modification practice varies greatly
because of different types and levels of experience
and the availability and quality of home modification
training and education and building advice.
Although occupational therapists might not be
involved in the whole home modification process,
they could still be required to provide the client with
assistance and advice at any stage. For example,
occupational therapists may be contacted to undertake the whole home modification process; they
may be required to work with the client up to the
point of identifying interventions; they may need to
check modifications proposed by alternative parties
to provide advice on their suitability or whether
changes are required; or they may need to visit the
client to train him or her in the use of the home
modification after it has been installed. At times, the
therapist might be required to visit a person’s home
to examine a modification that is not achieving the
desired outcome to suggest alternative interventions. The timing and extent of occupational therapists’ involvement during the home modification
process depend on whether the referrer and other
85
stakeholders understand the role or contribution of
occupational therapists in the home modification
process and whether occupational therapists have
sufficient knowledge and expertise in the area. With
a good understanding of the role of occupational
therapists, other parties concerned, such as clients,
health and community care professionals, program
administrators, insurance companies, lawyers, and
design and construction professionals, can involve
therapists constructively throughout the process.
Occupational therapists with appropriate knowledge
and experience can demonstrate the benefits of their
involvement at various stages and can be called on
repeatedly to contribute their expertise.
ROLE AND VALUE OF THE
OCCUPATIONAL THERAPIST
IN RECOMMENDING MINOR
MODIFICATIONS
Minor Modifications: It’s Not as
Simple as “Do It Yourself”
A minor modification is sometimes considered a
simple solution that can be implemented through
a “do-it-yourself” approach, but many situations
are more complex than is immediately apparent.
Minor and major home modifications have not been
clearly or comprehensively defined in much of the
international legislation informing policy and service development. This has resulted in a divergence
of opinion about how home modification services
should be defined and delivered and who needs to
be involved in recommending and installing these
alterations. There is a limited understanding outside
the profession of the value of minor home modifications. Further, there is ongoing debate both outside
and within the profession about the role of occupational therapists in working with consumers to make
minor home modifications. Naive understandings of
the home modification practice result in the perception that minor modifications are simple and able
to be undertaken by anyone. This approach can be
problematic, especially considering the complexity
associated with the process of determining the most
appropriate solution. When the complexity of the
process is not acknowledged and addressed and an
occupational therapist is not considered or included
in this process, poor home modification outcomes
may result.
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Chapter 5
Figure 5-1. Framework of complexity associated with minor modification recommendations.
The Complexity in Home
Modification Decision Making
The simplicity of a home modification does not
always reflect the simplicity of the situation it is
addressing. Figure 5-1 presents a framework for differentiating between the simplicity and complexity
of the solution versus the simplicity and complexity
of the situation. A minor modification may be considered a simple solution, but the process used to
determine this minor modification may be complex.
Complexity may arise from factors associated with
the person, their occupation, and/or how the environment presents. The complexity of the situation (i.e.,
the person’s circumstances, the way in which they
undertake activities in the home, and the immediate
and broader socioeconomic/legislative environment)
affect home modification decisions and outcomes.
Achieving good outcomes requires a well-considered
home modification approach that includes a clear
understanding of products and design solutions so
they can be matched to the needs of the consumer
and the household. Occupational therapists possess
the knowledge and skills necessary to assist people
in identifying the best home modification solution.
Further information about this issue and this complexity is detailed in Appendix A.
STAGES OF THE HOME
MODIFICATION PROCESS
There are a number of stages in the home modification process, from the initial referral to the final
evaluation of the home modification and the education and training of the person in its use after installation. The specific stages of the home modification
process include the following:
Ô Receiving and analyzing the referral information
Ô Prioritizing referrals
Ô Arranging the home visit with the client
Ô Preparing for the home visit
Ô Traveling to the home and meeting the client
Ô Entering the property
Ô Interviewing and observing the client
Ô Inspecting the home
Ô Measuring the client and his or her equipment
and/or caregiver
Ô Photographing, measuring, and drawing the
built environment
Ô Planning, selecting, and negotiating a range of
interventions
Ô Concluding the home visit
Ô Seeking technical advice
The Home Modification Process
87
Ô Writing the report and completing concept
drawings
Ô Submitting the report to the referrer
Ô Educating and training clients in the use of
home modifications
Ô Evaluating home modifications and client outcomes after installation
Occupational therapists can enter and exit at various points of the home modification service delivery
process, depending on the type and level of service
required by the referrer, their knowledge and level
of expertise, and the expertise of other stakeholders
involved in the process.
Receiving and Analyzing the
Referral Information
The home modification process begins with the
occupational therapist receiving and analyzing the
referral information (Figure 5-2). There is a range of
reasons for seeking home modification advice from
occupational therapists. Clients might have a newly
diagnosed health condition, or they might have
experienced a recent injury that requires changes
to their existing home environment before they can
be discharged from care. Individuals might be aging
and experiencing increasing difficulty coping in their
current home situation. Home modifications might
be sought when people move to a new environment
that does not adequately support their occupational
performance. Alternatively, there might be changes
to someone’s social context or roles that affect the fit
between their performance skills and patterns, activity demands, and the environment (Siebert, 2005).
Requests for a home modification evaluation are
generally received from health practitioners and
community and home care service providers; however, increasingly, informed clients and caregivers are
contacting occupational therapists for home modification services. At times the need for home modifications may be identified as part of discharge planning
from an inpatient or rehabilitation facility (Siebert
et al., 2014). Referrals can arrive by phone, e-mail,
fax, or letter and can contain variable amounts of
information. Most contain a general request for a
home evaluation because of an individual’s health
condition, injury, or increasing frailty. Some referrals
seek a specific environmental intervention (e.g., grab
bars beside the toilet) or are requested as a prevention strategy (e.g., to reduce the risks of falls; Siebert
et al., 2014).
The referral stage signals the start of information
gathering. As therapists review referrals, they note
Figure 5-2. Receiving and analyzing the referral information.
essential information, such as the client’s name,
address, and age. This background information and
other details, such as the person’s disability, health
condition, or age-related changes, might be entered
into a service database to assist with recording
and tracking service requests and events. Existing
records, if available, are to be reviewed to determine
whether clients have been seen previously and the
nature of services they have accessed. Prior to the
visit, therapists might need to carry out research on
specific disabilities or health conditions, their presentation, and functional implications to understand
them more fully in order to develop hypotheses
about their likely impact on occupational performance and potential environmental barriers. Such
information can help therapists think through the
range of suitable interventions in advance of the
home visit. Further, an understanding of prognoses
alerts therapists to future equipment and support
requirements and/or alternative ways of undertaking
tasks that might need to be considered when planning interventions.
Other referral information of interest is whether
the person is currently using equipment or receiving
assistance in the home. If occupational therapists
are not familiar with the equipment information
provided, they might have to undertake background
research to ensure that they are well informed about
the specifications of the equipment and how such
devices can be used. Caregiver or family support
information provides a prompt for the occupational
therapist to ensure that these people are present at
the time of the home visit and to engage them in the
home-visit process (Klein, Rosage, & Shaw, 1999).
It is also important to note who lives at home with
the client and whether there are any regular visitors
or guests. People who use the home environment
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Chapter 5
regularly will also need to be consulted when devising environmental interventions, especially if substantial changes are to be made to the home that
may affect how they interact with and use the
environment.
Information about the treating doctor, therapist,
nurse, or other service providers is also required to
ensure that relevant providers can be contacted for
further information, such as details about medical
treatment, rehabilitation, or equipment that might
be prescribed, or to discuss the suitability of proposed interventions. It should be noted, however,
that informed consent must be obtained from the
client before making contact with these providers.
The referral might include information about the
style of home and any environmental barriers being
experienced. The details about the style of home can
provide an indication of any other environmental
barriers in addition to those already documented.
For example, knowing that a person with mobility
impairment is living in an older, two-story house
alerts the therapist to examine the condition of the
stairs, stair usage, and range of activities undertaken on the upper level.
Some specialist home modification providers and
private therapists have developed a dedicated home
modification referral information form to gather
referral information and document other background information essential to providing timely
and appropriate service. The quality of referral information varies greatly in detail and quality. Referrers
generally provide information on client demographics, background information on the person’s disability and/or health condition, and a general statement
of need. However, in order to prepare effectively for
the visit, therapists require additional detail, including the following:
Ô The referrer and accompanying documentation
Ô The current use of equipment and health and
community services
Ô The style of the home and existing environmental barriers
Ô The type of modification/service requested
Ô The ownership of the home
Ô The need for an interpreter or formal or informal decision maker
Ô The presence of other household members
In addition, to assist therapists in establishing
timelines for service provision, they:
Ô Require critical time frames (e.g., the client’s
expected discharge date)
Ô Need to know the level of safety and risk to the
client in his or her current situation (e.g., the
prevalence or likelihood of accident or injury,
restricted activity, or unwanted dependence)
Figure 5-3 is a sample home modification referral
information form. When therapists make their initial
phone calls to clients to set up a time for their home
visit, this is a good opportunity to discuss occupational performance issues experienced in the home
and to explain the role of the occupational therapist.
Clients’ expectations can be clarified in relation to the
home modification and the timing, duration, and process of the home visit. Information gathered during
these calls might also highlight additional issues (e.g.,
that the client is not eligible for a particular service
and might require a referral to an alternative service).
Prioritizing Referrals
Occupational therapists often have to prioritize
their work and allocate their time judiciously, especially if their services are in demand. Referrals are
generally prioritized in light of the urgency of each
individual client’s need, as well as the relative importance with respect to other referrals (Bradford,
1998). Factors to consider when prioritizing referrals
are listed in Table 5-1.
When considering the urgency of referrals, therapists consider whether clients are at risk of being
involved in an adverse event resulting in reduced
activity, injury, institutionalization, or premature
death if they are not visited immediately. Those who
are at a high risk are prioritized as being urgent.
For example, an urgent home visit may be required
if a referral indicates that the client has had falls in
the home, has been hospitalized, and is not able to
return home without adequate services and modifications. Alternatively, a visit may be considered
nonurgent if the client has activity limitations that
can be improved in the short term with the use of
equipment that can be purchased or borrowed or
if they have care support in the home. Once the
urgency of each client is determined, clients are then
prioritized based on the degree of risk in relation to
other people on the waiting list.
When determining the level of urgency, therapists
need to determine and record the likelihood of an
adverse event occurring and the consequences of an
event. For example, in the urgent case described earlier, the therapist would record that the client was
highly likely to receive an injury resulting in further
hospitalization should he or she return home without appropriate interventions. The nonurgent case
would be recorded as being unlikely to result in an
adverse event in the form of an injury and that any
activity restrictions could be mitigated by the use
of equipment while awaiting a home modification
assessment (Table 5-2).
The Home Modification Process
89
Occupational Therapy Home Modification Referral Information Form
Demographic Information
Client name:
Address:
Phone number:
Date of birth:
Gender:
ID number:
Referral Information
Date of referral:
Referral source (including contact details):
Client’s advocate or spokesperson (including contact details):
Does the client require an interpreter?
Does the client wish to have a particular person at the interview? If so, please provide the person’s name and contact
details.
Type of Referral
Home modification:
Postmodification evaluation:
Other:
List of Documentation Received
Confidential medical report from a doctor or other medical personnel:
Authority to request or disclose client information:
Other:
Health Condition or Disability Information
List client’s health condition or disability or details about any age-related changes:
Is the client’s condition permanent, improving, deteriorating, temporary, or stable?
Has the client experienced a recent significant change in function or mobility? Describe.
Has there been a recent significant change in function or mobility?
What medication is the client taking for their conditions?
How many times has the client been hospitalized in the last 12 months?
What were the reasons for the client’s hospitalization?
Is the client receiving family or informal caregiver assistance or community services to assist with self-care or household
tasks, or access within the community?
What community services or informal support services are being received by the client (include information on the
treating doctor, therapist, nurse, or other service providers)?
Does the client live alone, with a caregiver who is well, or with a caregiver who is aging or has a health or medical
condition?
Figure 5-3. Sample occupational therapy home modification referral information form. (continued)
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Chapter 5
Description of the Client’s Equipment
List the items of equipment that the client is currently using in the home and community to assist with mobility and
day-to-day activities:
Description of the Home Environment
Describe the style of the client’s home:
Is home owned or rented? If rented, state length of lease.
Description of the Environmental Barriers
Describe the environmental barriers being encountered by the client:
Describe the impact these barriers have on client or caregiver functioning:
Description of the Client’s Home Modification Request:
Urgency of Home Visit
Provide an opinion on home modifications requirements:
Describe urgency of need for home modifications:
Occupational Therapist’s Comments:
Signature Block
Staff Person Receiving Referral
Name:
Position Title:
Signature:
Date:
Facility or Agency:
Program:
Occupational Therapist Receiving or Reviewing Referral
Name:
Signature:
Date:
Facility or Agency:
Program:
Figure 5-3 (continued). Sample occupational therapy home modification referral information form.
The Home Modification Process
91
Table 5-1. Considerations When Prioritizing Referrals
PRIORITY
High
Moderate
Moderate to low
Low
RESPONSE
See within the week
See within few weeks
See within 2 months
See within 6 months
CONSEQUENCE
Event likely to
result in death or
hospitalization
Event likely to result in
compromised health
or performance
Event likely to
compromise
independence
Event likely to affect
quality of life and
participation
LIKELIHOOD
High likelihood of
adverse event
Moderate likelihood
of adverse event
Low likelihood of
adverse event
Adverse event unlikely
TYPE OF
LIMITATION
Transfers, mobility,
and hygiene activities
such as toileting and
bathing
Other self-care
activities such as
eating and dressing
Cleaning, shopping,
cooking, laundry
Leisure and community
participation
ABILITY TO
FUNCTION
Unable to perform
essential elements of
the activity
Difficulty performing
essential elements of
the activity
Difficulty performing
Little difficulty
some essential
performing essential
elements of the activity elements of the activity
ALTERNATIVES
No viable alternative
possible
Alternative method
or equipment option
possible, but does not
address issue fully
Alternative method or
equipment option can
temporarily address
issue
AVAILABLE
SUPPORT
No alternative support No alternative support No alternative support Alternative support
available
available onsite, but
available onsite, but
available onsite
can be purchased
can be accessed at
no cost
TIMING
Palliative condition
Chronic/lifelong
condition
Fluctuating condition
Acute, short-term
condition
SOLUTION TYPE
Minor and/or major
modifications
Minor and/or
major modifications,
equipment
Minor modifications
and equipment
Equipment only
Alternative method
or equipment option
possible
Table 5-2. Client Examples Illustrating Prioritization Information and Resulting Level of Urgency for a Visit
NAME
SUSPECTED
ENVIRONMENTAL
HAZARD/BARRIER
CONSEQUENCE
LIKELIHOOD
URGENCY OF
HOME VISIT
Mrs. Jones
Slippery bathroom floor
High—injury because of
a fall
Likely—already been
hospitalized
High
Mrs. Smith
Low toilet
Minor—reduced activity
performance
Low—can be managed
with additional equipment or
caregiver support in interim
Low
Where cases are not easily assessed as being high
or low risk, various resources and tools are available to assist with decision making. For example, as
illustrated in Figure 5-4, any event that is considered
likely or almost certain with a major or critical consequence would be considered extreme and therefore classified as extremely urgent. Any event that
results in a moderate, major, or critical level of consequence and could be unlikely, possible, likely, or
almost certain to occur is also considered to be high
risk and therefore urgent. When events are likely to
be rare to almost certain to occur and have a range
of consequence from insignificant to major, they are
considered a lower risk and priority to those listed
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Chapter 5
Figure 5-4. Risk assessment chart. (Adapted
from Australian Standard
for Risk Management [AS/
NZS ISO 31000:2009].)
earlier. Events that have insignificant to major consequence but are rarely likely or are likely to occur
are low risk and priority.
Unfortunately, services may not have prioritization tools to assist clients and occupational therapy
practice. The presence of these tools depends on
the concern of organizations in relation to client
wait lists, and their policies and procedures in
relation to delivery of client services. Prioritization
tools are required to ensure that services direct
their resources to meet client need without disadvantaging people and being challenged about their
service delivery processes. Prioritization tools are
important for occupational therapists to use when
justifying services and bidding for resources. They
provide clear guidance to funding bodies as to why
some clients are seen before others.
Considerations affecting the prioritization of clients include:
Ô The service context (e.g., hospital, community,
or private practice) and the overall priorities
of the service (e.g., the care requirements of
clients in relation to the safety of caregivers)
Ô Other available services that the client might
be referred to while awaiting an occupational
therapy visit
Ô Whether a phone call to a client with discussion about interim options can assist in the
initial stages of the referral, particularly if there
is a wait list for services
Arranging the Home Visit With
the Client
Once the priority of the referral has been determined, the occupational therapist contacts the client
by phone, e-mail, text message, or letter within the
recommended time frame that may be established
by the therapist or the organization to arrange the
home visit (Figure 5-5). Alternatively, the client may
be advised that he or she has been placed on a waiting list and will be contacted in the future to arrange
an appointment, assuming personal needs do not
change. If clients are on a waiting list, they should be
advised to contact the home modification program
and the occupational therapist should their situation change. Clients might need to be reprioritized if
their need for a visit becomes urgent or if their risk
of accident, injury, or institutionalization increases.
An informal or formal decision maker, service
provider, guardian, or family member might need to
be contacted if the client requires assistance to communicate their requirements. In such cases, documented informed consent should be sought from
these representatives before information is gathered
about the client.
The Timing and Duration of the Home Visit
The timing of the home visit is generally determined by the urgency of the client’s situation and
the availability of the client and other members of
the household to meet. Clients at high risk of injury
will need to be seen urgently, whereas others can
be scheduled routinely. The timing of the home
The Home Modification Process
visit might also need to be planned around the
expected date of discharge from the hospital. If the
client requires urgent home modifications to ensure
his or her safety, the occupational therapist might
undertake a home visit before or immediately after
discharge. If it is not possible to complete all the
required work in time, the therapist might recommend basic modifications and plan a second visit
to discuss other interventions after the client has
returned home. In some instances, when the person
has recently acquired a disabling condition, the occupational therapist might delay the visit until after the
person has been living in the home for a short period
and has had time to settle into his or her new routine
and identify the environmental barriers. This can
help the client make well-informed decisions about
the issues and interventions required. When arranging home visits around the availability of the client,
it is important to be aware that clients are often reliant on others for help with their self-care and home
management routine and medical appointments.
Therefore, occupational therapists may need to
arrange the visit around other scheduled activities.
The duration of home visits varies and should
be negotiated with the client when making the
appointment. Generally, occupational therapists can
anticipate the time required for the visit based on
the referral or the initial conversation. Alternatively,
the service or reimbursement system may allocate a
specific amount of time for home visits as defined by
the client’s health condition or the identified need.
However, sometimes the complexity of the situation
might only become evident during the visit.
A range of issues can affect the timing and duration of the home visit. These include the following:
Ô The energy levels of the client: The client might
have limited physical, cognitive, or psychological capacity, which means that he or she can
only manage short visits or visits conducted at
times during the day or week.
Ô The number of people in attendance to contribute to the decision-making process: The
occupational therapist might need to negotiate
an appointment time to suit several people and
spend considerable time listening to the views
of the client and others when gathering information and negotiating a range of intervention
options.
Ô The amount of equipment used: The occupational therapist might need time to undertake
extensive measurement of the client, his or
her equipment, and the home environment
to determine the person’s body dimensions,
reach range, circulation, and storage space and
93
Figure 5-5. Contacting the client to arrange a home visit.
dimensions and location of fittings and fixtures
in the environment.
Ô The number and nature of occupational performance difficulties being experienced: If the
person is having trouble with several activities,
the occupational therapist will need to allocate
a reasonable time frame to ensure that performance in each activity is adequately evaluated.
Ô The number and type of barriers in the home
environment: Some houses present numerous
barriers to performance; others present challenges to being modified. The occupational
therapist might need to take numerous photos
and approximate measurements and seek technical advice from design or building professionals before proposing interventions. The greater
the number and extent of environmental and
construction barriers, the more time required
to problem solve and plan the interventions.
If considerable time is required to evaluate the
person, his or her occupational performance, and
the home environment, the visit time may need to
be extended or additional visits booked (Silverstein
& Hyde, 1997). If the occupational therapist has been
allocated only a limited time for the home visit, he or
she will need to negotiate with the client and formulate a mutually agreeable structure for the interview,
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Chapter 5
allocating a specific time for each stage of the visit,
including the interview, observation, measurement,
walk-through of the home, and discussion of intervention options.
Clients should be advised to have all concerned
parties present at the visit. Involving the various stakeholders in the home modification process
ensures that all relevant issues are discussed and
carefully considered and that intervention options
developed are acceptable and useful to everyone
affected by them (Klein et al., 1999). Further, involving stakeholders at the time of the visit is likely to
reduce the number of discussions and meetings,
phone calls, and/or subsequent visits required to
consult with various parties.
If clients rely on equipment to undertake different
activities in the home, they need to be advised to
have devices available at the time of the home visit.
This allows the occupational therapist to measure
the items and observe their use in the home. Further
home visits might be required if the client does not
have his or her equipment available at the time of
the initial home visit, particularly if the equipment
dimensions and space requirements (with or without
a caregiver using the equipment) are likely to affect
the design of the home modification.
Preparing for the Home Visit
Being well prepared ensures that the home visit
is productive and efficient. Occupational therapists
prepare for home visits by doing the following:
Ô Filling in interview forms with relevant referral
information in advance of the visit
Ô Gathering required home visiting resources
Ô Compiling appropriate forms and evaluation
tools for information gathering
Ô Collecting evaluation and environmental measurement tools
Ô Collating information on various intervention
options
Prior to the visit, therapists should read the referral information and any other background information on record and transfer relevant information
onto forms to be used during the visit. It is also useful to take the referral documentation on the visit to
confirm and clarify information with the client.
Therapists should ensure that they gather a range
of resources that can be used during a home visit,
including the following:
Ô Personal identification information, such as an
identification badge
Ô A clipboard and pens or computer technology,
such as a laptop or tablet
Ô Occupational therapy evaluation tools, including interview guides, checklists, and report
forms (if they are not on a computer or tablet)
Ô Paper and pencils for drawing diagrams
Ô A cell/mobile phone
Ô A street directory or satellite navigation system
for directions to the property
Ô Water
Ô Written information on whom to contact in
the event of an emergency, such as a car
breakdown
Ô A first-aid kit in the vehicle
The forms that need to be taken on home visits
can include an interview form with prompts, a home
visit checklist with specific features in different
areas of the home, and privacy and consent forms
for use when information needs to be sought from
other service providers, such as the doctor, hospital
therapists, or home and community care nurses.
Occupational therapists may need to take photos of
the person and/or areas of the home, which might
require the client’s written permission.
Evaluation tools such as the Canadian
Occupational Performance Measure (Law et al.,
1998), Performance Assessment of Self-Care Skills
(Rogers & Holm, 2007), Safer-Home (Chiu & Oliver,
2006), Housing Enabler (Iwarsson & Slaugh, 2001), In
Home Occupational Performance Evaluation (Stark,
Somerville & Morris, 2010), and other standardized
tools can be used to establish a picture of the person-environment-occupation transaction and provide a base measure of performance for comparison
with outcomes measures (Law & Baum, 2005).
The choice of environmental measurement tools
depends on the environmental barriers highlighted
in the referral information. It is useful to have a
kit that holds the following tools, with appropriate
instruction sheets and forms in hard copy or electronic format, on all home visits:
Ô 18-ft (5-m) tape measure to measure dimensions
Ô Electronic distance meter to measure long
distances
Ô Camera (and spare batteries) for photos of the
environmental barriers and the client’s equipment to keep as a record from the visit and to
incorporate into the home modification report
Ô Light meter to measure lighting levels
Ô Force measure to measure the amount of force
required to open doors and drawers
Ô Electronic clinometer to measure the horizontal gradients of landings, paths, ramps, floors
The Home Modification Process
Ô Pegs, string line, and spirit level for setting out
the proposed configuration of an outdoor ramp
Prior to the visit, therapists also need to research
and collate resource information to take with them
to assist with intervention planning. The resource
information might include the following:
Ô Concept drawings (site and floor plans or elevations) or photos of modified environments to
show the client examples of completed work
Ô Access standards or guidelines and/or local
building codes relevant to the type of home
being visited (to discuss specific design requirements with the client)
Ô Photos and product information (e.g., brochures or information from the internet) to
show the client illustrations of home modification designs and products and equipment
solutions
Ô Products such as taps and grab rails to enable
the client to see and feel items
Ô Equipment such as an over-toilet frame or
a bath board that can serve as a less-costly
alternative to a home modification. These items
may be taken on the home visit to try and
evaluate their suitability for the client and the
environment.
Safety Considerations
Prior to the visit, it is important that occupational
therapists evaluate potential risks to themselves
and the client during the home visit and ensure that
safety measures are put in place.
Communicating the Home Visit Schedule
As a safety precaution, occupational therapists
should advise their fellow workers of their schedule,
including the addresses and phone numbers of the
clients they will be visiting, the time and expected
duration of these visits, and their cell/mobile phone
number. Staff working in private practice might need
to identify a suitable contact and advise this person
of the time of their visits and their exact whereabouts, especially if they work on their own, outside
of business hours, or in isolated locations.
Identification and Clothing
Occupational therapists should have personal
identification on them at all times. They should also
ensure that their appearance and clothing are appropriate and reflect community standards, in particular those that meet the expectations of the older
generation. For example, when visiting older people,
it is advisable for female occupational therapists to
wear trousers rather than skirts to enable them to
95
maintain their modesty while moving into various
positions during measuring. It is also preferable that
occupational therapists not wear shirts with plunging necklines or shorts or jeans that are low cut or
ripped. Therapists should also wear enclosed shoes
with low heels because they are likely to be walking
on a variety of surfaces, both within and outside
of the home. Shoes that can be slipped on and
off easily allow occupational therapists to remove
shoes before entering the house. When visiting construction sites, clothing and shoes should comply
with work health and safety requirements. In such
situations, occupational therapists may need to wear
hard hats for head protection and steel-tip boots for
foot protection.
Personal Safety, Training, and Support
Therapists need to be conscious of the environments they are entering and the background of
the people they are visiting. They need to gather
information about the home environment such as
the location and available phone reception, whether
there are animals present and if they will pose a
threat to safety, and the person’s current health status prior to their visit to ensure the therapist is safe
at the visit.
It is always advisable for occupational therapists
to carry a mobile phone at the time of the home visit.
On arrival, they need to ensure that their vehicle is
in a safe, well-lit, easy-to-access location near the
premises. The car should be parked on the street
or in a designated parking area in the direction of
exit from the street and should not block residents
or caregivers needing access to and from the home.
A visual check of the property on entry can also
provide information about whether there are pets
that might pose a safety risk to visitors. Discussion
might be needed about restraining pets if the therapist is concerned about the animal or feels that it
might disrupt the home visit.
Inside the premises, therapists should ensure that
they position themselves between the client and the
exit to ensure obstacle-free egress in the event of an
adverse event. If the client or other householders
exhibit any suspicious or unusual behavior, it may be
prudent to conclude the visit and exit the premises.
It is advisable to record this information on file or
report it to a supervisor on returning to the office.
Similarly, if an adverse incident occurs at the time of
the home visit, the therapist must advise a supervisor as soon as the home visit is completed and make
a record of the incident on file.
Where therapists are dealing with remote, complex, or challenging clients, it is advisable for them to
undergo personal safety training. At times, it might
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Chapter 5
Figure 5-6. Driving to the client’s home.
Figure 5-7. Entering the property.
be necessary to take another person along on a visit.
For example, if a client lives in a remote region that
requires hours of driving, a second person might be
required to share the driving and ensure safety in
a remote location. When clients are frail, unwell, or
live alone, the occupational therapist might require
assistance to assess the person’s safety in performing a range of activities in their environment. If an
occupational therapist is visiting a client who has
just left a mental health facility or prison or has a
history of becoming aggressive toward others, he or
she might need another staff member for support.
Entering the Property
Traveling to the Home and
Meeting the Client
The home visit process begins well before the
therapist reaches the front door of the client’s home
(Figure 5-6). Occupational therapists survey the
community and gather information en route to the
person’s home (Klein et al., 1999). They observe the
location of local facilities in relation to the client’s
premises; type and location of public transport;
general topography of the district; presence and
condition of footpaths, curbs, and roads in the surrounding area; and style and condition of housing
in the neighborhood. By observing the client’s surroundings, therapists can gain an understanding of
why people may choose not to relocate, particularly
if they are located close to community facilities or
support services. Reviewing the surroundings also
provides detail of the potential environmental barriers to participation in the community. It enables
therapists to ensure that modifications to the exterior of the home will fit with the look of the rest of
the street and neighborhood.
Prior to the visit, occupational therapists should
ensure that they have the client’s permission to
enter the property (Figure 5-7). On walking to the
front door, the therapist may notice aspects of the
external layout of the home that might affect the
client’s occupational performance. For example,
the therapist might note the slope of the land just
outside of the boundary for street access to the site,
height and style of fencing for privacy, slope of the
land within the boundary, and presence of any paths
and steps. It can also be noted whether paths are
free of hazards and obstacles, the number of risers
on the stairs, the condition of the steps and handrails, the presence of light fittings, and the age and
style of the home. These are potential barriers to
occupational performance that may require further
discussion and consideration (Figure 5-8). The wider
dimensions of home also should be considered when
entering the property, taking note of the appearance
and style of the exterior of the home, for example.
If the client is not at home or does not answer
the door, the therapist might call the client’s phone
number provided. If there is no answer, the therapist
might leave a business card with a note indicating
the time of the visit. If there is evidence that the
client may be at home and there may be concerns
about this person’s personal safety, the therapist
might call the contact person listed in their documentation or the police to seek assistance.
When meeting the client at the front entry, the
therapist should introduce him- or herself, show
identification, and confirm that the client is available to begin the home visit and is comfortable with
the therapist entering the home. As a courtesy, it is
suggested to ask whether shoes need to be removed
before entering the home.
The Home Modification Process
On entry, the therapist should observe the environment to ascertain his or her level of personal
safety. If there is any feeling of unease for any reason
during the home visit, the therapist needs to discontinue the visit and exit the premises. If there are no
perceived threats, the visit can proceed and the therapist can establish a presence in the home. The occupational therapist should ask the client and other
householders where they would be most comfortably
seated and ensure that this location is well suited to
conducting an interview and viewing resource materials. The occupational therapist then takes the seat
suggested by the client. The therapist may politely
request that seating be rearranged, the radio or television be turned off, or lights be turned on to create
a more conducive interview environment.
If the client offers a drink, the therapist can accept
it and use this time to establish a rapport. It is also an
opportunity to begin to understand the client’s experience of home, commenting on, for example, the
view; the décor; or the prints, objects, or photos on
display. Using this approach, clients come to understand that the occupational therapist is interested
in their story and that he or she values their experiences and meaning of home. This is an important
first step in creating a collaborative relationship with
clients, where they feel valued as experts in their
own lives and homes. A useful opening question to
gather a wealth of information about the client’s connection to home is, “How long have you lived here?”
This often allows people to share their history of
home, whether it is home with many memories and
a place they wish to remain, or a place that is new
to them that they are not familiar with or perhaps a
place that they do not enjoy living in. The therapist
might also use this opportunity to observe the client
as he or she prepares the refreshments, noting any
concerns about mobility and ability to structure and
complete the task, as well as concentration and communication during the activity. The therapist should
be aware that performance during this activity may
not be representative of the person’s usual performance and that hypotheses formulated at this time
need to be confirmed through further evaluation.
The therapist might note the layout and condition of
the home, existing obstacles, and color and lighting
of the rooms and discuss issues of concern with the
client as they become relevant during the interview.
When the client is finally seated, the therapist
makes a full introduction, providing information
about the home modification program, his or her
role, and the purpose of the visit. The therapist
should introduce him- or herself to everyone present
and develop an understanding of each person’s relationship with the client and his or her place in the
home and its routines. The therapist may also need
97
Figure 5-8. Observing the property features and the client.
to clarify each person’s role in any decision making
to do with modification of the home environment.
For example, the client’s husband might have been
involved in building and maintaining the home and
would therefore need to be consulted about changes;
a community care nurse might provide assistance
during bathing and would therefore need to be
consulted about modifications to the bathroom; the
client’s daughter might be concerned about disruptions to the household that would necessitate her
accommodating her parents if major modifications
are undertaken.
In different situations, the occupational therapist
might have to vary the way the visit is conducted.
For example, the therapist might sit and complete
the interview first before asking the client to show
how he or she currently undertakes activities in
various areas of the home. Alternatively, the client
may be anxious to discuss his or her concerns and
show the problem areas in the home first to ensure
that the occupational therapist is clear about the
issues. The therapist might also decide that viewing
the home is important before the interview because
it could provide important information on the layout of the home and specific fixtures and fittings.
Regardless of the order of events, it is essential that
the therapist gains all of the information required
before discussing interventions.
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Chapter 5
Information gathered at the time of the interview
is documented to ensure a record of the detail
is retained (Stark, 2003). Occupational therapists
may use one or more of the following to document
information:
Ô A notebook for handwritten interview notes or
drawings
Ô Paper forms with key headings or checklists to
guide the interview process
Figure 5-9. Interviewing the client.
Interviewing the Client
At the start of the interview process, the occupational therapist discusses his or her role in ensuring
the privacy and confidentiality of the information
gathered and asks the client to sign the consent
forms. The therapist confirms the referral information and the background details with the client to
ensure these are accurate (Figure 5-9). During the
interview, the therapist listens to the person’s story
to understand the following:
Ô The person’s health condition and concerns
Ô Activities, routines, and roles within the home
and community
Ô Use of the various areas of the home
Ô The personal meaning of the home, including
objects, spaces, and features within the home
Ô The history of the home
Ô The person’s future hopes and dreams in relation to his or her home (Siebert, 2005)
The occupational therapist can use a series of
open and closed questions to develop a deeper
understanding of the person, his or her occupations, and occupational performance concerns and
barriers in the home environment. This questioning process involves identifying and defining issues
of importance to the client and understanding the
history and routines within the household and
how these may influence the nature, feasibility, and
appropriateness of interventions (Siebert, 2005).
The client’s wants, needs, occupational risks, and
problems are evaluated, and information is gathered, synthesized, and framed from an occupational
perspective (AOTA, 2014). This information is then
considered as the occupational therapist observes
the client undertaking various activities in the home
at a later stage in the visit.
Ô Personal computers (handheld or laptop or tablet) that contain documents with key headings
or checklists. This technology may be used to
type in responses directly or convert handwriting to text and upload photos so that changes
can be drawn on the photo directly.
Ô Digital pens and dedicated documents with key
headings or checklists. The digital pens can
record handwriting and concept drawings or
convert these to text and electronic diagrams.
The type of technology used depends on a range
of factors, including the therapist’s experience with
and confidence in using technology; the cost, availability, and reliability of the technology; the organization’s position on its use for home visiting; and
access to technical support.
Inspecting the Home
During the visit, the therapist examines the environment carefully to develop a full understanding
of its layout, structure, fixtures and fittings, and the
barriers to occupational performance (Figures 5-10
through 5-16). Of interest will be:
Ô External access around the home: Access to the
mailbox, trash cans, clothesline, pool, greenhouse, front, and back yards, and the front gate;
the quality and type of paths, stairs, ramps,
and driveway areas
Ô Internal access within the home: The layout of
the home (open plan or with corridors); location and number of internal stairs; number of
bedrooms and route of access to the various
areas of the home; changes in floor levels and
the types of floor finishes
Ô Kitchen, bathroom, laundry, and bedrooms:
Layout and the types of fittings and fixtures
Ô Car parking facilities: Space, lighting, and
access
Ô Access to the vehicle or public transport:
Access from the car parking facility to the
home, the distance to public transport facilities
The Home Modification Process
Figure 5-10. Inspecting the home with the client.
Figure 5-11. Observing the client.
Figure 5-13. Measuring the client’s equipment.
Figure 5-12. Observing the client.
Figure 5-14. Measuring the client’s reach range.
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Chapter 5
Figure 5-15. Measuring the client’s equipment.
A walk-through also offers an opportunity to
gather information about the dimensions of the
home to understand what might be important about
the home for the client and their family and how
this may affect decision making. For example, the
aesthetic and style of the home may be important
to consider when thinking about the appearance of
grab rails or a ramp. A walk-through of the different
areas with the client will enable the occupational
therapist to analyze the physical environment and
its potential to enhance or constrain occupational
performance (Siebert, 2005). It will also afford the
client an opportunity to show where occupational
performance difficulties occur. The occupational
therapist then uses skilled observation and occupational analysis to analyze the client’s occupational
performance as he or she demonstrates activities of
concern or simulates elements of activities, such as
transfers, bending, lifting, and reaching (Klein et al.,
1999). The therapist listens to the client’s concerns
and then observes his or her performance, analyzing
the sequence of activities and discussing how, when,
where, and why the difficulties occur with the client
(Ohta & Ohta, 1997). This ensures that the hypotheses formulated by the therapist about the person’s
capacity at the time of referral and interview are
fully explored and validated or refuted as appropriate. Examining occupational performance in different areas of the home with the client ensures that he
or she understands how the current design and layout of the home, or the existing fittings and fixtures,
might hamper occupational performance and allows
the therapist to discuss potential interventions.
Figure 5-16. Measuring the environment.
Measuring the Client, Equipment,
and Caregiver
The occupational therapist might need to measure the client, his or her equipment, and the caregiver to determine the required size of openings and
circulation spaces and the location of fittings and
fixtures (see Figures 5-14 through 5-16).
When the client’s dimensions are required, the
therapist measures the following:
Ô Height, width, and length of various body parts
Ô Reach range in seated and/or standing positions
Ô Eye height and examines his or her visual fields
In addition, the therapist measures the height,
length, width, and circulation space of the equipment and caregivers. The therapist also checks the
positioning and movement of the client with the
equipment and caregivers in relation to managing
the spaces, fittings, and fixtures. This information
ensures that spaces can be designed to optimize the
ease of approach and use and that fixtures and fittings are within reach.
If there are going to be multiple users of a specific
area, the anthropometrics of all users will need to be
The Home Modification Process
101
Figure 5-18. Planning, selecting, and negotiating interventions.
Figure 5-17. Measuring the environment.
considered in the redesign of space and placement of
fittings and fixtures, with adjustable options being
integrated into the design if necessary.
Photographing, Measuring, and
Drawing the Environment
Concept drawings and photographs can become
a valuable record of the home visit and can be used
to complement the written detail in the report.
Therapists are reminded to seek permission from
clients to photograph, measure, and draw areas of
the home.
Photographs
Therapists may take photos of key areas and
features in the home from various angles to ensure
that comprehensive information is collected.
Photographs can be useful in reports because they
add visual detail about the home and environmental
barriers. Digital photographs can be easily inserted
into word processing or presentation software/apps
and can be annotated by hand or electronically to
highlight barriers and illustrate where the modifications are to be installed.
A digital photo might also be useful for the therapist to discuss the environmental barriers and range
of solutions with the client if he or she is not able to
access an area of the home. Printouts can be drawn
on to illustrate the location of the proposed modifications or shown on the screen of a portable device.
Photos can also serve as a record of the environment
before, during, and after the home modification and
can be a visual aid for informing other clients, their
families, and caregivers about alternative environmental interventions.
Measurements
The occupational therapist needs to collect a
comprehensive set of measurements of the problem
areas in the home environment (Figures 5-17 and
5-18). Measurements of features that are working
well for the client should also be taken so that these
dimensions can be incorporated in any redesign.
The type of measurements taken will depend on
the environmental barriers or enablers identified.
Measurements can include lengths, widths, depths,
and heights of fittings, fixtures, and the circulation
spaces in problem areas of the home. It might also
be necessary to measure the spaces adjacent to or
along a path of travel to these areas, as these areas
might need to be incorporated in the final redesign.
It is advisable to collect any additional measurements that might be useful if alternative solutions
need to be explored at a later stage.
All relevant measurement information, including
concept drawings of the layout of specific areas in
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Chapter 5
Chapter 8 provides information on drawing the
built environment.
Planning, Selecting, and
Negotiating Interventions
Figure 5-19. Reviewing the professional drawings.
floor plan and elevation views, is recorded at the
time of the visit and is incorporated in the design of
the modification.
Chapter 7 provides further information about
measuring the person and the environment.
Concept Drawings
Measurements of the environment are recorded
on a concept drawing, which can be used when
communicating design requirements to various
stakeholders.
Therapists employ various drawing methods,
depending on their expertise and the type of work
they do. They may choose to take only approximate
measurements and create concept sketches to send
on to a skilled contractor or building design professional to refine and develop into scale architectural
drawings. Alternatively, therapists may develop simple concept drawings, drawn to scale, to ensure that
there is adequate space for circulation and fixtures
and fittings in the proposed design before passing it
on to building and design professionals for detailed
drawings. Therapists should check the level of service they are required to provide with their licensing
boards to ensure that they do not work outside of
their scope of practice with respect to the creation
and provision of drawings.
Once a draftsperson or builder has developed
a scale drawing, the therapist needs to review the
drawing and evaluate the usefulness of the design
for the client and other people involved in the household. Consequently, a plan review may be undertaken with the client and others. A scale ruler is used
during a plan review to confirm that required clearances and circulation spaces have been included in
the design and that the plan supports the movement
of the person, their equipment, and carer during
activities.
An individual’s occupational performance can be
enhanced through a range of interventions, such as
seeking alternative ways to undertake activities, providing assistive devices and social supports, and/or
modifying the home environment (Figure 5-19). Once
therapists have a clear understanding of the client’s
occupational profile and his or her key occupational
performance issues, they can select, review, negotiate, plan, and implement a range of suitable interventions. When designing interventions, therapists draw
on theory, practice models, and research evidence
and use professional reasoning to choose the best
solution for each situation (AOTA, 2014; Fisher, 1998;
Schell, 2014).
Occupational therapists collaborate with clients
to establish short- and long-term goals related to
occupational performance in the home and community (Grayson, 1997). Short-term goals might include
addressing problems associated with performance
components or environmental issues; long-term
goals might be to maintain or enhance the performance of daily occupations related to performing
different roles in the home and community (Law &
Baum, 2005). Once the client’s goals are identified
and prioritized, the therapist works with him or her
to identify the interventions to address these goals
(AOTA, 2014).
When an extensive number of changes is required,
staff may need to discuss the list of recommendations with clients and, if relevant, caregivers, so that
items can be prioritized (Connell & Sanford, 1997;
Silverstein & Hyde, 1997). Prioritizing home modifications is especially important if there are issues
relating to costs, funding, and timing of the work.
Factors Influencing Intervention Options
The process of planning and discussing intervention options with the client can be a complex undertaking influenced by a range of factors: client related,
therapist related, and environment related.
Client-Related Factors
Occupational therapists should consider various
areas of the home as they talk through the range
of intervention options. Clients may be unable to
change when and how specific activities are undertaken and therefore may be reluctant to consider
some intervention options. However, they can also
grow accustomed to reduced levels of performance
The Home Modification Process
and underestimate the barriers in the home environment (Pynoos, Sanford, & Rosenfelt, 2002; Wylde,
1998). Interventions can also have an impact on the
physical, social, cultural, personal, spiritual, and
temporal elements of the home environment, which
should be considered carefully when selecting and
negotiating modifications (Aplin et al., 2015; Hawkins
& Stewart, 2002).
Other factors that can affect the selection, negotiation, and acceptance of home modifications include
the following:
Ô The cost of the modification: Clients might
not have the funds to make changes to their
home, especially if most of the home modifications are to be self-funded, as they generally
are (American Association of Retired Persons
[AARP], 2000). In addition, some modifications
require additional structural or maintenance
work to be undertaken before the modification
is completed, which is often at a cost clients
can ill afford (Jones, de Jonge, & Phillips, 2008).
Ô The person’s knowledge of the range of possible intervention options: Without a clear
understanding of what is possible, clients are
often not able to envision how their situation
can be improved (Jones et al., 2008).
Ô The person’s perception of the need, usefulness, and acceptability of the intervention:
Clients are more likely to accept an intervention if they believe it supports their sense
of personal identity. Conversely, interventions
that undermine their sense of identity are
unlikely to be welcomed (McCreadie & Tinker,
2005).
Ô The availability of information about arranging
the work: Clients are better able to undertake
a modification if they understand the building
process: how to choose and engage a contractor, how the work would be done, how to manage in the home while the work is underway,
and how to cope with any mess caused by
contractors (AARP, 2000; Duncan, 1998; Pynoos
& Nishita, 2003).
Ô The amount of disruption the intervention is
likely to cause: Clients are sometimes reluctant
to undertake extensive work in areas such as
the bathroom if it will be out of commission for
a period.
Therapist-Related Factors
Interventions recommended by occupational
therapists are likely to be influenced by their own
level of knowledge, skill, and experience in the
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home modification field, as well as their model of
practice. For example, occupational therapists with
a wide-ranging knowledge of domestic products,
design standards or guidelines, and resources and
who undertake postmodification evaluation of previous work are likely to have a wealth of valuable
information and experience that they can draw on.
Therapists who use an ecological or transactive
model of practice are also more likely to address
occupational performance difficulties using environmental interventions than therapists who use models
focused on remediating performance components.
Environment-Related Factors
When considering modifications for the home,
the team and the client need to consider a range of
factors relating to the suitability of the dwelling for
alteration, including the following:
Ô The cost-effectiveness of any changes, given
the size, value, age, and structural suitability of
the home (Connell & Sanford, 1997; Silverstein
& Hyde, 1997)
Ô Building rules and regulations relevant to the
redesign of the area to ensure compliance with
the law
Ô The fit of any modification with the style and
design of the dwelling and existing streetscape,
if the work is located outside of the home
Ô The long-term viability of the design and suitability to current and future householders.
Current design trends, such as universal design,
aim to ensure that products and designs are
“useable by all” (Center for Universal Design,
1997) and reduce the likelihood that the modification needs to be altered or removed later as
the needs change (Ringaert, 2003).
Ô The dimensions of the home (outlined in
Chapter 1) provide a comprehensive list of
environmental factors that have been found to
influence home modification decision making.
Other Factors
In most services, there are policies and procedures relating to home modification recommendations and a specific range of resources available to
assist in the planning of interventions. Legislation,
industry standards, and design guidelines might also
guide the design and implementation of environmental interventions (Ringaert, 2003).
Chapter 4 provides information on legislation influencing home modification practice, and
Chapter 11 provides details about access standards
and their role in guiding interventions.
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Chapter 5
Ô A shopping center to try the gradients of accessible ramps
Ô Another client’s home to see the home
modifications
Information gleaned from these trials can be used
to confirm or guide the redesign of proposed home
modifications.
Chapter 9 provides information on developing
suitable interventions, and Chapter 10 provides
detail about sourcing and evaluating products and
designs.
Concluding the Home Visit
Figure 5-20. Concluding the home visit.
Educating Clients About
Proposed Interventions and the
Modification Process
Throughout the process of selecting and negotiating interventions, the therapist has a responsibility
to inform the client about the extent of change to
an area required, the range of people to be involved
in the process and their respective responsibilities,
and the expected time frame for the modification
work. In addition, the therapist should discuss
the expected impact of the home modification on
the way activities would be undertaken and the
expected appearance of the final modification. The
therapist might show the client photos and diagrams
of the layout of a room to help him or her better
understand how it will look and how he or she might
be able to move through or use the area.
Some occupational therapists find it useful to take
clients to facilities that have already been modified
to allow them to move around in the space and try
the fittings and fixtures. This may include visiting:
Ô A demonstration home or display center to
view and try accessible design features
Ô A hydrotherapy center to try an accessible toilet, vanity unit, and shower recess
At the conclusion of the home visit, the therapist
should provide the client with a brief verbal summary of the outcomes from the visit and confirm
the full range of issues and options to be included in
the home modification report (Figure 5-20). It is also
beneficial to leave a brief written summary of the
proposed interventions and an action plan stating
who is responsible for each step of the plan. At this
time, it is important to ensure that the client agrees
with the recommendations. If the client does not
agree, the therapist should extend the visit or make
another time for further discussion and negotiation
with the client and other stakeholders. If technical
advice is required on the proposed modification, the
therapist might also arrange to visit with a designer
or builder before the interventions are finalized and
the home modification report is written and submitted to the relevant body for approval.
Seeking Technical Advice
Technical building advice is sometimes required,
particularly where home modification work is
expected to be extensive or if the client and occupational therapist are not clear about whether the
home can structurally accommodate the modification. Because occupational therapists do not receive
training in construction and renovation of buildings,
they consult with experts, such as design or building professionals, who provide expertise on design
and building matters. For example, a therapist might
need to know whether:
Ô A wall can support a grab bar
Ô A wall can be removed to allow more circulation space without compromising the integrity
of the roof
Ô Light fittings and power points can be of a particular type and positioned in specific locations
in a bathroom under national plumbing and
electrical code requirements
The Home Modification Process
105
Ô A garage can be converted into an extra bedroom under local building regulations
Ô A ramp can be designed with an appropriate
gradient to suit an area with limited space or if
the yard has a slope
Ô A proposed extension of a home is possible
under local building regulations
Ô A stair lift can be installed on stairs leading to
several units under the building regulations
Design or building professionals generally contribute to the design and construction of modifications by:
Ô Noting environmental barriers and constraints,
including property boundaries, immovable
structures, or items that will affect the design
(e.g., protected trees and fire-rated or loadbearing walls)
Ô Systematically measuring relevant areas and
noting the position of services and other permanent fittings and fixtures, such as windows
and doors
Ô Deciding on the structural work required, such
as modifying the levels or finishes of the floor
and removing, moving, or installing new walls,
doorways, or windows
Ô Deciding on the changes required to services,
such as the location of electrical points, water
pipes, or drains
Ô Planning the location of fittings and fixtures
Ô Drawing the redesigned area to scale
Ô Finalizing product finishes, such as flooring
and surfaces, lighting, and color options
Ô Providing an estimated cost of the works
Issues discussed among the occupational therapist, design or building professional, and client
might include the following:
Ô The feasibility of the proposed environmental
modification, such as whether the home modification is reasonable given the age and type
of construction of the home or whether the
changes can be easily and stylishly included in
the existing layout of the home
Ô The existing dimensions and space for the
home modifications, such as adequate floor
area to incorporate the home modification
Ô The required dimensions of the modifications,
such as length, height, width, or depth of spaces, fixtures, and fittings
Ô The range of products and features to be incorporated into the alterations, with consideration
Figure 5-21. Checking the built environment against the plans.
given to the specific needs of the client as well
as other people in the household
Ô The cost and design of the proposed work
in relation to the household budget and the
degree of design elegance associated with the
cost of the proposed modification
The information gathered from discussions with
the design and building professional might be included in the therapist’s report, or the design and building professional might provide a written technical
specification report with accompanying drawings
and photos. If the technical specification report and
drawings have more technical detail than the therapist’s home modification report, these should be
used by the contractor for quoting and completing
the work.
Reviewing Professional Drawings
To ensure that the developed drawings are consistent with those agreed to by the therapist in collaboration with the client, the therapist compares
them with those created by the design or building
professional (Figure 5-21). The therapist ensures
that all relevant information is included and that
there are no discrepancies, omissions, or inadequate
adherence to recommendations or design guidelines
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Chapter 5
or standards. Once the plans are reviewed, the
therapist provides a report on how the proposed
design will or will not meet the client’s needs and
either endorses the drawings or provides a report
about the discrepancies noted on the plans. This
report provides feedback to the design or building
professional and ensures the drawings are revised to
suit the client’s specific requirements. It may be necessary to undertake a plan review process with the
client to double-check the layout and measurements,
particularly if equipment was being scripted at the
time when drawings were being developed, or if
the client’s physical and functional changes require
alteration of features and fittings, new equipment, or
a greater level of carer support (i.e., one rather than
two carers).
Role Differences
It is important to note that design or building professionals are not trained to have an understanding
of a client’s health conditions and disabilities and
the associated impact on occupational performance;
hence, they have no expertise in evaluating the specific needs of clients. They are not trained to analyze
the person-environment-occupation transaction, to
identify a specific cause of performance difficulties,
or to determine how occupational performance can
be further enabled using a range of interventions.
Further, they are not skilled in measuring a person
with or without equipment and do not have expertise in determining future equipment and carer
requirements in relation to the person’s health condition or disability. The information that is gleaned
from measuring the person, the equipment, and
carer and anticipating future need can affect the current and proposed layout of areas within and outside
the home.
Building and design professionals do possess
important technical expertise on the design and
construction of buildings and surrounding environments, which can assist in the planning of environmental interventions. They are also experts at
providing drawings, specifications for other building
and design professionals, and costings for works
completion. Consequently, it is imperative that a
team approach is used in home modification practice so that various professionals can contribute
their unique expertise to the process and the design
of environmental interventions (Pynoos et al., 2002).
Writing the Report and
Completing the Drawings
Occupational therapists should document the
findings and recommendations as soon as possible
after the home visit. This will ensure that the details
of the visit are captured accurately in the report.
Notes and photos taken at the time of the visit can
also assist with recall.
The occupational therapy report should summarize information gathered at the time of the home
visit. It is also important that the therapist contacts
the client, family, or people assisting the client to
make decisions, or other service providers after the
visit to seek further information about the client’s
health condition or disability and their functional
capacity. As stated earlier, permission should be
sought from the client prior to contacting relevant
stakeholders. Some services require that client permission be recorded in writing and placed on file for
future reference.
It is important that therapists are clear about the
documentation requirements of the original referrer (the program or individual who will receive the
report) because each might have their own reporting
expectations. The report should be in politically correct language and worded simply so that it can be
clearly understood by the intended reader. Details
about whether information has been reported by the
client, family, caregivers, or others or observed by
the occupational therapist should be included. More
essentially, the report should provide a record of
the professional and clinical reasoning and decisionmaking process and not just the outcomes of the
home visit. If required, photos and drawings should
be incorporated into the report to provide a detailed
picture of the client’s circumstances and the areas of
the home environment requiring alteration. Finally,
the report should provide the client with a record
of the visit, including the issues and solutions discussed and the final recommendations.
The Structure of a Home Modification Report
Not all occupational therapists or home modification services stipulate a structure for home modification reports; however, it is recommended that
they establish a structure for these documents. For
example, some services might choose to document
the occupational therapy report in two sections as
follows.
The first section of the report should provide
background information about the client; their disability or medical condition; and any personal or
environmental impacts on their occupational performance, valued roles, occupations, and day-to-day
activities. Other background information can include
details of the equipment being used by the client in
the home and, where appropriate, the dimensions of
these items with and without the client. Information
on the client’s current living situation and use of
The Home Modification Process
support services should also be included in this first
section.
The report should detail the issues identified and
discussed during the interview as well as the options
explored. Justification for the final option should
also be provided, explaining why this is the best
option for the client and his or her situation. This
section should detail the specific needs of the client
and the physical, social, cultural, personal, and temporal aspects of the home that affect decision making. A statement might need to be made against each
recommendation, detailing the consequence of not
proceeding with the home modification, to ensure
the reader is clear about the proposal.
The second section of the report is a guide for the
building professional when undertaking the home
modification work. This section should incorporate
a general list of the modifications required, including
the location and dimensions of features, circulation
spaces and clearances, and performance requirements of products and finishes (Bradford, 1998).
The building professional does not need to read the
confidential information about the client contained
in the first section; he or she requires only the technical information to undertake the home modification work. It is therefore necessary that this second
section provides sufficient detail for the modification work to be undertaken successfully and, where
appropriate, include the detailed specification and
plans provided by the builder or architect. This
section of the report should be able to stand alone
in its own right and have sufficient detail to guide
a builder, particularly if the building professional’s
drawings and specifications become detached from
the occupational therapy report. It is not satisfactory
for the therapist to refer the reader to the builder’s
or architect’s report and not include a detailed summary of the home modification requirements in that
report. If the builder’s report is lost or goes missing, there would then be no detail in the therapist’s
report to guide the same or another builder. Further,
this section of the therapist’s report may be used
by several builders for quoting. It is not industry
standard for builders to quote off another builder’s
documentation, but it is acceptable to use the therapist’s documentation.
When making recommendations, it is preferable that therapists indicate only the performance
requirements of products rather than specify brands
to ensure no one company has a competitive advantage over others and to prevent the therapist from
being sued if there is product failure. This practice
also ensures that the builder can select from a range
of products. There might be specific occasions when
the client requires a particular product to suit his
107
or her needs. In such situations, occupational therapists might have to provide product information in
their report to ensure that the client’s needs are met
(Bradford, 1998).
It is important that therapists develop an intimate
knowledge of the wide range of products suitable for
use in home modifications. They should be familiar
with industry standards on how the product should
be manufactured, tested for safety, and labeled for
correct use.
Therapists can provide each client with a copy of
the report and its recommendations to ensure he or
she has a record to refer to while the work is being
undertaken. The therapist should be mindful that
the report, and any other associated documentation relating to the client on file, is a legal document
and might one day be used in court. It is therefore
important to consider the extent and type of information to be kept on file and included in reports.
Organizations have a specific policy in relation to the
release of reports that therapists need to consider
before providing documentation.
Submitting the Report
In the next step of the home modification process,
therapists submit the report for approval and action.
Some services require information only for the builder and do not need the client’s background information. In this instance, therapists can keep notes
on file for future reference and to comply with the
legislative requirements for storage of client records.
If therapists have provided sufficient justification
for the recommendations and details of the modification in the report, the work can be approved and
started. On occasion, the person or program providing the funding for the home modification might not
approve the modification; the alterations might be
considered too costly, too invasive, an inappropriate intervention given the client’s requirements, or
outside the scope of the provision of the program.
There might be requested changes to the recommendations, which would require another home visit
to renegotiate the interventions with the client. It is
important that therapists be clear about the parameters of the program before making recommendations
because this will inevitably save time. However, they
should always ensure that their recommendations
are in the best interests of their clients and provide
them with sufficient information to make informed
choices. Clients might decide to fund their preferred
option themselves. Alternatively, therapists might
refer clients to another service should their needs
fall outside the scope of the existing service or
funding.
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Chapter 5
Figure 5-22. Reviewing the impact of the home modifications
on the client’s occupational performance.
Figure 5-23. Observing the client using the home modifications.
If therapists are in doubt about what might be
approved, they could propose a range of options in
the home modification report, from the least costly
and least invasive option through to the ideal solution that may be more expensive. It is important that
therapists clearly document their clinical reasoning
in relation to the proposed interventions, the level
of importance or priority assigned to these interventions, and the consequence of each for the client.
Documentation is also to include details about the
consequence of not proceeding with the recommendations. This information will provide helpful detail
for the decision maker as he or she reads the report.
Further information about ethical, legal, and
reporting issues can be found in Chapter 12.
Ô Caregivers need to use the modification when
assisting the client (Siebert, 2005)
Further education and training in the use of modifications may be required if the client has demonstrated difficulty managing alternative interventions.
This training may need to be delivered over several
sessions depending on how the clients manage with
the initial instruction for use.
Therapists might also provide contact information for repair or maintenance (Bradford, 1998) so
that the client can contact the supplier or builder
for assistance if problems arise during the warranty
period.
Educating and Training Clients in the Use of
Home Modifications
Occupational therapists have a role in educating
and training clients in the use of modifications once
they have been installed. This training is particularly
relevant in situations where:
Ô The modifications have been extensive
Ô The person’s impairments are newly acquired
Ô The person’s occupational performance has
declined over time
Ô A range of equipment has been considered in
the planning of the modification
Evaluating Home Modifications
and Client Outcomes After
Installation
The home modification process concludes with
the occupational therapist inspecting the modification and other interventions to determine whether
the home modifications have been installed properly
and that they have achieved the desired outcomes
for the client, are effective, and have not presented
any unexpected impacts or difficulties (Figures 5-22
and 5-23). The therapist also confirms that the
modifications and interventions have met client
expectations and fit in with the look and feel of the
The Home Modification Process
home and household routines. In addition, they discuss whether the client’s occupational performance
has been supported or enhanced through the new
interventions. Further changes might have to be
made if the modification has not helped the person’s
occupational performance or if it has created further
environmental barriers.
The postmodification inspection can involve therapists taking a walk-through of the property with
clients to examine the effectiveness of the modifications and/or comprise a formal evaluation of the
outcomes of the modification using a standardized
evaluation tool. In the first instance, occupational
therapists might complete a detailed review of
the products and finishes installed and check the
specific measurements to ensure that the home
modification has been completed per the therapist’s
documented recommendations and drawings or per
the design or building professional’s specification
and drawings.
Therapists should inform clients (or advocates)
if they identify problems resulting from poor workmanship, incorrect installation of fittings and fixtures, or delays with work completion by tradesmen.
To act in this capacity, they will need to understand
the relevant legislation, such as building or antidiscrimination legislation, to help resolve issues. They
will also need some knowledge of advocacy and
building service organizations that can assist in the
resolution of disputes.
Improved occupational performance is the expected outcome of occupational therapy interventions
(Backman, 2005). Performance outcomes discussed
during the initial evaluation process (at the time
of interviewing and observing the client) can be
revisited after the modification to note any change
in that performance. By using standardized tools to
identify goals and evaluate performance, therapists
can assess the extent of change following the modification. This information is invaluable in informing
practice and demonstrating the effectiveness of
home modification practice.
Further information about evaluating client outcomes can be found in Chapter 13.
At the conclusion of this process, the occupational therapist discusses the discontinuation of services with the client to ensure they are clear about
the process. Services from the therapist should
cease if the occupational performance goals have
been achieved or if the goals have not been met but
the person has progressed as far as he or she can
toward these goals, if he or she has received the
maximum benefit of occupational therapy services,
if unforeseen circumstances arise (such as the client
109
relocating or dying), and if no further home modifications are required (Siebert et al., 2014).
CONCLUSION
This chapter described how occupational therapists receive and analyze referral information with
a view to prioritizing their visit in relation to other
referrals. After contacting clients to arrange a suitable time and preparing and collating required
resources in advance of the visit, therapists travel to
the clients’ homes, where they complete interviews;
inspect the homes; measure the clients and their
equipment and/or caregivers; and photograph, measure, and draw the built environment. They sit with
the clients to plan, select, and negotiate a range of
interventions before concluding the first visit.
This chapter has also discussed how technical
advice may be required from professionals with
design or construction expertise before the report
and drawings are finalized and submitted to the individual or organization providing funding approval.
Information has been provided on the valuable role
of occupational therapists in educating and training
the client in the use of the home modification and
evaluating its effectiveness after installation and use
by the client.
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Schell, B.A.B., & Schell, J. W. (2008). Professional reasoning as
the basis for practice. In B. A. Boyt Schell & J. W. Schell (Eds.),
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(pp. 3-12). Philadelphia, PA: Lippincott, Williams & Wilkins.
Siebert, C. (2005). Occupational therapy practice guidelines for
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Siebert, C., Smallfield, S., & Stark, S. (2014). Occupational therapy
practice guidelines for home modifications. Bethesda, MD: The
American Occupational Therapy Association Press.
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Stark, S. (2003). Home modifications that enable occupational
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Stark, S., Sommerville, E. K., & Morris, J.C. (2010). In-Home
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Technology and Disability, 8, 51-68.
Evaluating Clients’
Home Modification
Needs and Priorities
6
Desleigh de Jonge, MPhil (OccThy), Grad Cert Soc Sci and
Melanie Hoyle, BSc (Psych), MOccThySt, Grad Dip Health Sci, Post Grad Dip Psych
In occupational therapy, evaluation is viewed as
a collaborative process that aims to understand
people as occupational beings and how they create
meaning in their lives through occupation (Cohn,
Schell, & Neistadt, 2003). A home evaluation seeks
to understand and analyze the dynamic transaction
between people, their occupational patterns, and
the home environment. Using a top-down approach
and an occupation-based framework, occupational
therapists analyze occupational performance by
first seeking to understand the roles and occupations of importance to the person and the impact of
the injury, impairment, or health condition on the
person’s life. The therapist then observes and examines the person’s performance, the home environment, and occupational elements (activities, tasks,
and sequences) to identify barriers and facilitators
to performance. Clients are considered central to
the evaluation process, actively contributing to the
therapist’s understanding of their experience and
capacities, the value of the activities they engage in,
and the intricacies of the home environment.
Given the unique and complex nature of occupational performance in the home, therapists rely
heavily on professional reasoning to deal with the
diversity of information they gather during the evaluation process. This chapter describes the range of
reasoning styles therapists use and how they are
used throughout the process to develop and test
hypotheses, understand the client’s perspective,
and determine what is achievable to ensure the best
possible outcomes. The chapter also details the variety of evaluation strategies therapists use to understand and interpret occupational performance in the
home, including informal and structured interviews,
skilled observation, and standardized assessment
tools, and discusses what each strategy contributes
to the home modification process. Criteria are also
provided to guide therapists when they are selecting
and evaluating standardized assessment tools.
CHAPTER OBJECTIVES
By the end of this chapter, the reader will be able
to:
Ô Describe the purpose of a home evaluation
- 111 -
Ô Explain the framework therapists use for evaluating occupational performance in the home
Ô Describe how professional reasoning is used
throughout a home evaluation
Ô Identify the types of evaluation strategies occupational therapists use during a home visit and
what each contributes to the evaluation process
Ô Identify important considerations in choosing standardized assessment tools for home
modifications
Ainsworth, E., & de Jonge, D. An Occupational Therapist’s
Guide to Home Modification Practice, Second Edition (pp. 111-144).
© 2019 SLACK Incorporated.
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Chapter 6
PURPOSE
OF
EVALUATION
When providing a home modification service, the
purpose of an occupational therapy evaluation is to
gain an understanding of the clients’ skills and abilities and the barriers that prevent them from successfully completing the necessary and valued activities
in their home. The home is a natural environment in
which the therapist and client can develop a shared
understanding of occupational performance issues.
It is here that therapists can observe their clients
undertaking everyday activities and see what is completed and how and where they are usually done. By
using a range of evaluation strategies, the therapist
identifies “misfits” involving the person, occupations, and the environment. Throughout the visit,
the therapist monitors the environment and talks
with people who live in the home to understand the
dimensions of the home environment that influence
occupational performance and are likely to affect
decision making.
Therapists undertake evaluations in the home to:
Ô Ensure that clients being discharged from a hospital or institution are safe and able to undertake basic self-care activities independently
Ô Identify fall risks, especially in the homes of
older people and people with a history of falling
Ô Ensure that people with congenital and acquired
impairments (e.g., cerebral palsy, stroke, spinal or head injury, Parkinsonism) are able to
mobilize safely and function effectively in their
home environments
Ô Ensure that older people, including those with
and without an identified health condition, are
able to remain living in their homes for as long
as possible
Ô Assist families to care for children, teenagers,
or adults with impairments
Home is where many and varied occupations
are undertaken (Rigby, Trentham, & Letts, 2014).
It is where people commonly eat; rest; look after
themselves and others; and manage their finances,
goods, and resources. It is where they develop and
maintain relationships or refresh and replenish their
energies through a range of restful and active leisure
pursuits. It is the base from which they engage in the
community and explore the world. Some activities
happen routinely on a daily or weekly basis, whereas
others happen seasonally or periodically. Home
evaluations generally involve an assessment of the
person’s ability to perform valued and important
occupations in the home. Depending on the person’s
roles, goals, and priorities, an evaluation would
generally include an assessment of self-care and
household activities, as well as those to do with leisure and community participation. Some evaluations
focus primarily on the accessibility or safety of the
home and community.
Evaluations generally take a number of forms.
First, they are used as a means of screening (i.e.,
determining whether a person requires occupational
therapy services and how urgently). Evaluations
also assist therapists to analyze and identify the
nature and, in some cases, the extent of the occupational performance issue. Finally, evaluation allows
therapists to determine whether there has been
a change in occupational performance as a result
of occupational therapy intervention. This is commonly referred to as outcome measurement. Each of
these evaluation approaches uses different strategies, although some traverse a number of purposes.
Screening
Screening involves a cursory evaluation of the
person’s occupational performance to determine
whether a more thorough evaluation is required
(Shotwell, 2014). This can take the form of a brief,
informal interview with the person (or the referrer)
to determine whether he or she has any specific
occupational performance concerns or is at risk of
developing associated problems. Therapists commonly use structured questioning to understand the
nature of the person’s impairment or health condition and its current and future impact on occupational performance. Therapists also briefly explore
the demands of various roles and activities and
the nature of the home environment and potential
impacts on occupational performance (Law & Baum,
2017). Alternatively, they use standardized tools to
evaluate the person’s capacity to perform a range
of activities or identify environmental hazards that
may place the person at risk of occupational performance difficulties in the home. Both informal and
structured questioning rely on the therapist’s experience and professional judgment to decide whether
the client requires a service and how urgently it
should be delivered. The information gathered using
standardized assessments provides a mechanism
for determining the extent of a performance problem, which can be used to justify and prioritize service provision. In addition, information gained from
screening all referrals can assist in determining the
extent of need generally in the community.
Evaluating Clients’ Home Modification Needs and Priorities
Analyzing and Diagnosing
Occupational Performance
Therapists are primarily familiar with using evaluations to analyze and diagnose occupational performance difficulties. These evaluations require a
thorough approach to information gathering and
analysis and are essential to designing effective
interventions. Therapists generally use a range of
evaluation strategies to understand the precise
nature of the occupational performance difficulties
being experienced and to identify aspects of the person-environment-occupation transaction that are
contributing factors.
Therapists use a range of evaluation strategies
to identify and analyze occupational performance
issues. Informal and structured interviews provide
background information on clients and their living
environment and help therapists develop an understanding of client concerns and their perspective on
the nature and impact of occupational performance
problems. Therapists also use skilled observation to
closely examine occupational performance, identify
where performance is ineffective or hazardous, and
investigate factors contributing to inadequate performance. These observations are often undertaken in
a semistructured way with performance described
qualitatively, which relies heavily on the professional experience and judgment of the therapist.
Therapists also use standardized assessment tools
to measure the extent of the performance problem
and diagnose the cause of the presenting problem.
Evaluation of Outcomes
Outcome evaluation assists therapists to determine the effectiveness of home modification interventions. These evaluations are undertaken to confirm that the changes have produced the desired
improvements in occupational performance and to
ensure there are no adverse consequences resulting from the introduced changes. The consistent
use of outcome measures is also fundamental to
evidence-based practice (Law & Baum, 2017). These
evaluations inform therapists about the most effective interventions in a range of situations and build
a body of evidence of their value and effectiveness.
This information is being used increasingly by policy
makers and management to make decisions about
policy directions and the future funding of various
service programs (Law & Baum, 2017). Outcomes
can be evaluated qualitatively and quantitatively.
Qualitative evaluation provides an opportunity to
record the client’s and therapist’s perception of the
impact of the intervention. Quantitative evaluation
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can demonstrate the extent of impact and establish
whether there have been any measurable changes
as a result of the intervention, especially if standardized measures are used before and after the event.
FRAMEWORK
FOR
EVALUATION
In home modification practice, it is important
that the evaluation strategies chosen reflect clientcentered practice so that clients are empowered by
the process and have a sense of ownership of the
modifications undertaken in their home. Evaluation
methods should allow clients to identify their specific concerns about valued occupations, record their
unique occupational performance requirements, and
document the impact of interventions on their lives
(Law, Baum, & Dunn, 2017). This requires that evaluation strategies do the following:
Ô Allow occupational performance issues or
problems to be identified by the client and
household members and not solely by the
therapist and team
Ô Permit the unique nature of each person’s participation in occupations to be recognized
Ô Provide opportunities for both the subjective
experience and the observable qualities of
occupational performance to be recorded
Ô Afford the client (and relevant others) to
have a say in evaluating the outcomes of the
interventions
Ô Recognize the unique qualities of the home
environment
Ô Assist clients and household members to develop a mutual understanding of therapists’ safety,
prevention, or health maintenance concerns
(Law & Baum, 2017)
Client-centered evaluation requires that evaluation strategies extend beyond the measurement
of performance components. Evaluation strategies
need to be able to measure the extent of occupational engagement, giving due recognition to the uniqueness of each person’s valued roles and occupations.
They should also allow the client and therapist to
jointly plan interventions (Law & Baum, 2017) and to
determine the effectiveness and value of these to the
client in the short and long term.
Evaluation should also accurately reflect the scope
and focus of the profession and its practice frameworks. When using the occupational therapy practice
framework, evaluation focuses on understanding the
person’s occupational history and experiences and
his or her patterns of daily living, interests, values,
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and needs, as well as his or her priorities and concerns about occupational performance (American
Occupational Therapy Association [AOTA], 2014).
Occupational performance is observed in context in
order to determine supports/facilitators or barriers
to performance, giving due consideration to body
structures and function, performance skills and patterns, and activity demands as well as the environment. The therapist, in collaboration with the client,
then determines concerns and risks and identifies
problems and the probable causes.
When using an ecological approach, evaluation
should focus on the quantity and quality of occupational performance using both objective and subjective methods. It examines the “fit” of the person, environment, and occupations, acknowledging that these
are constantly changing and evolving. These models
recognize the unique personal attributes, capacities, and life experiences each individual brings to
the collaboration. Evaluations need to examine the
physical, sociocultural, personal, and temporal elements of the environment and the potential impact
of these on occupational performance. It would also
consider these environmental domains from an individual, household, neighborhood, and community
perspective.
PROFESSIONAL REASONING
As a result of the individual and complex nature of
home modification practice, therapists rely heavily
on professional reasoning throughout the evaluation
and intervention process. Whereas medical settings
refer to clinical reasoning, the term professional reasoning has evolved to acknowledge the range of practice settings occupational therapists work in. This
section focuses on the use of professional reasoning
during evaluation. The role of professional reasoning in designing acceptable, effective, and workable
home modification interventions will be discussed
further in Chapter 9; however, good reasoning in
the evaluation process is critical to developing a
thorough understanding of the issues, which then
contributes to developing effective interventions
and achieving good client outcomes.
Therapists use a “whole body” process (Schell,
2014) to understand occupational performance in
the home, identify factors that constrain performance, and create a home environment that enables
occupational engagement. Using a combination of
theoretical knowledge and personal and professional experience, therapists analyze copious amounts
of diverse information to fully understand each
person and his or her occupational performance
issues. They can then recommend interventions that
will fit well with each unique person-environmentoccupation transaction.
Therapists use a combination of thinking
approaches to understand occupational performance issues in the home environment: scientific,
narrative, pragmatic, ethical, and interactive reasoning (Schell, 2014). For example, from the moment
therapists receive a referral, they begin to gather
information and use scientific reasoning to anticipate occupational performance difficulties or generate hypotheses from their bank of theoretical
knowledge of impairments and health conditions
and the role the environment plays in creating disability. Therapists continue to use scientific reasoning throughout the evaluation process when choosing appropriate evaluation methods and analyzing
and interpreting behavior. When talking with their
clients and listening to their stories, therapists use
narrative reasoning to develop a deeper understanding of people’s lifestyles, aspirations, concerns, and
valued occupations. They then work with their
clients throughout the visit to develop a rich understanding of their experiences and environments
and to explore and create a new future. Pragmatic
reasoning assists therapists to use their personal
resources to their best advantage, understand the
service delivery context, and work sensibly and
effectively within the policy framework and available resources. Ethical reasoning ensures that the
therapist maintains respect for the values and rights
of all clients and provides the best possible service
in every situation. Finally, interactive reasoning
promotes the development of a strong therapeutic
relationship between the therapist and the client,
which builds a collaborative alliance and enhances
the potential for success of therapeutic interventions. Professional reasoning has been described
as “a dynamic process simultaneously influenced
by the client and therapist’s characteristics, experience, and background” (Radomski, 2008, p. 45). The
dynamic nature of professional reasoning is particularly evident when therapists use a client-centered
approach, where they need to be flexible and responsive to the uniqueness of each person and his or her
home environment.
Scientific Reasoning
What Is Scientific Reasoning?
Scientific reasoning is described as “a logical process that parallels scientific inquiry” (Schell, 2014, p.
388). Two forms of scientific reasoning are described
in the literature: diagnostic reasoning and procedural reasoning (Schell, 2014). Diagnostic reasoning
Evaluating Clients’ Home Modification Needs and Priorities
is concerned with sensing and defining professional
problems (Schell, 2014), and procedural reasoning
is the thinking that comes from choosing suitable
evaluation and intervention approaches (Fleming,
1991, 1994). In combination, these processes assist
therapists to progress from defining to resolving
occupational performance problems (Chapparo &
Ranka, 2000). Drawing on relevant bodies of knowledge, the therapist seeks and interprets cues and
then generates and tests hypotheses (Rogers &
Holm, 1991) about the person’s occupational performance difficulties and contributing factors.
How Is It Used?
The process begins with the therapist gleaning
cues from the written referral, case file, preliminary
conversation with the client, presentation of the
neighborhood, appearance and design of the home,
and initial encounter with the client. For example, Glenda, an older woman with osteoporosis, is
referred for a home assessment following a fall. The
therapist would initially determine her age, living
situation, general health, and whether she sustained
any injuries from the fall by reading the referral or
file. He or she would ask Glenda about her health
(including her vision, physical condition, memory,
cognition, medication use, etc.) and the circumstances of the fall to identify potential precipitating and
contributing factors. During the visit, the therapist
would note the age, design, and state of repair of the
house, and he or she would scan the environment
for known hazards. He or she would also observe the
client as she walks outside and within the house and
note her agility and ability to negotiate obstacles and
changes in lighting levels and flooring. These are
the cues that provide therapists with initial information about clients and their physical and functional
status, their occupations, and their home environments, which assist them to generate hypotheses
about the person’s occupational performance.
How Does It Influence the Evaluation Process?
The cues sought and noted by therapists are
shaped by their knowledge, experiences, and models
of practice. For example, a therapist’s knowledge of
factors that contribute to falls would direct him or
her to collect information about a client’s fall history,
number of medications, and so forth. Knowing about
the consequences of a fall for someone with osteoporosis also alerts the therapist to investigate this
and other comorbidities. Therapists with experience
working with people with a history of falls would be
alert to features in the environment that could be
injurious during a fall. The various models to which
therapists ascribe also define what they attend to
and what they understand to have contributed to
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the observed problem. A rehabilitation therapist
might focus primarily on measuring the extent of
the person’s functional impairment; therapists using
an occupational performance model would focus on
understanding how the person undertakes activities, whereas those using an ecological model would
examine the environment and how well it supports
activity engagement. Within clinical practice, therapists often draw on a number of models to develop a
comprehensive understanding of the person and his
or her situation.
When using diagnostic reasoning, therapists draw
on existing knowledge to acquire and interpret cues
and generate and test hypotheses. From a given
diagnosis, therapists can anticipate functional difficulties and hypothesize about how these are likely
to affect occupational performance and progress in
the long term. In addition, therapists analyze and
interpret behavior in an effort to understand what is
contributing to it. If Glenda were to trip when walking to the bathroom during the home visit, the therapist might attribute this to wearing poor footwear,
being distracted, a developing dementia or neurological impairment, vision loss, reduced sensation,
or uneven carpet. These hypotheses would then be
tested or adjusted as further cues are sought and
interpreted. For example, the therapist might ask
Glenda to demonstrate how she gets in and out of the
shower recess. By asking her to remove her shoes
and talking about how her legs and feet feel on the
floor and shower recess surface, the therapist can
test whether the problem persists without footwear.
Allowing her to concentrate on the task allows the
therapist to observe her performance without distractions. Observing her capacity to notice and lift
her feet over obstacles or level changes on the floor
enables the therapist to test her concerns about
Glenda’s physical and cognitive function. Her ability
to negotiate changes in floor level and uneven carpet
allows the therapist to examine the impact of environmental barriers on Glenda’s performance.
Procedural reasoning is used to choose appropriate evaluation strategies, including valid and reliable assessment tools (Radomski, 2008). Therapists
select strategies and tools that allow them to gather
information about the person, his or her occupations
and the environment, and the transaction between
them. A combination of observation, assessment,
and discussion allows various hypotheses to be modified and tested until the therapist develops a clear
understanding of occupational performance and the
person-environment-occupation transaction.
What Does It Offer the Therapist and Client?
Scientific reasoning allows therapists to draw on
their knowledge and experience to gather, analyze,
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and interpret vast amounts of information. When
therapists are well informed and able to use this
information to generate a number of hypotheses,
they are well placed to observe and interpret the
person-environment-occupation transaction and
understand how and why occupational performance
difficulties occur. This complex process is often easier for experienced therapists who have integrated
their model(s) of practice, have acquired a broad
knowledge base through experience and reading,
and have developed the capacity to attend to and
simultaneously process a diverse range of information. Less experienced therapists often struggle to
use their model(s) of practice and limited knowledge
effectively, to attend to a number of cues at the same
time, and to generate multiple hypotheses. This can
result in a tendency for them to jump to conclusions
quickly if time is not taken to critically reflect on
assumptions (Chapparo & Ranka, 2000). Experienced
therapists are also at risk of “contracting” to routine
practices if they over-rely on experience, do not keep
their knowledge current, or actively reflect on their
reasoning processes (Chapparo & Ranka, 2000).
Although scientific reasoning might appear to be
the realm of the therapist, clients also benefit from
this form of reasoning. When therapists are able to
share their knowledge and articulate their reasoning, they can engage clients in a meaningful and
informative discussion about risks and potentially
contributing factors. This allows the client to be an
active part of the issue identification and decisionmaking process rather than feeling uninformed,
disempowered, and pressured by “expert” opinion.
Narrative and Conditional
Reasoning
What Is Narrative Reasoning?
Occupational therapy has been described as both
an art and a science (Peloquin, 1994; Townsend &
Polatajko, 2013). Narrative reasoning, which addresses the art of the profession, contrasts with and compliments scientific reasoning. Narrative reasoning is
used to understand and describe a person’s unique
experience of his or her situation and to work with
that person to create an impelling future. It assists
therapists to make sense of each person’s situation and imagine the impact of the illness, injury or
health condition, aging, or disability on their lives
(Schell, 2014).
How Is It Used?
Throughout the home visit, therapists engage in
natural conversations with the householder, making
comments about spaces in the house and asking
questions such as, “Did you decorate this room yourself?” and “Are these photos of your family?” This
generally elicits storytelling that assists in developing rapport and gaining a richer understanding of
the home and the people living in it. Therapists also
use semistructured interviews to gather information.
These interviews can include open-ended questions
that allow clients to describe their experience in the
home. This allows therapists to draw information
from these stories to enrich their understanding of
the impact of the health condition or impairment
on a client’s engagement in activities in the home
and gain information about his or her occupational
history. It also provides the client with an opportunity to introduce new or unexpected elements to the
story that might not have been uncovered through
direct or closed questioning. Active and empathetic
listening is also important in building rapport and
encouraging clients to openly share their experiences and aspirations. Creating a safe space for
disclosure might be as simple as agreeing to have a
cup of tea and listening without interjecting, instead
allowing the client to discuss things that are important to him or her.
By taking the time to talk with and listen to Glenda,
the older woman described previously in this chapter, the therapist develops a rich understanding
of the impact of her condition on her day-to-day
roles, routines and activities, and the significance
of her home environment. He or she would learn
that Glenda was experiencing an increasing number
of falls and that this was making her feel unsafe in
her home and reluctant to go out without someone
accompanying her. Consequently, she finds herself
doing less and feeling even more uncertain. The therapist also learns that Glenda had lived in the house
for 45 years of her married life and had raised five
children in this home. Of significance is that she now
lives alone in the home that her recently deceased
husband built. Glenda is reluctant to make changes
because the home provides her with a strong connection to him and their family. She also looks after
two of her young grandchildren after school, bathing
and feeding them before her daughter collects them
after work.
Narrative reasoning is not only useful for developing a deeper understanding of each person and his
or her personal preferences and priorities, it is also
valuable in assisting clients to explore and create a
new future for themselves. When discussing issues,
the therapist has an opportunity to share stories
with a client and create new possibilities and a future
for him or her. For example, therapists can sometimes assist clients to articulate and analyze their
Evaluating Clients’ Home Modification Needs and Priorities
concerns by sharing stories about other people’s
experiences. Stories also help clients envision possibilities and create goals that may have been long
abandoned. For example, when discussing a recent
experience with a client with similar reservations
about going out into the community, the therapist
shared a story about how a simple modification to
the front entry of the house had provided the client
with greater confidence and a sense of security when
entering and exiting the house. This story allowed
Glenda to contemplate developing goals she might
not otherwise have considered.
How Does It Influence the Evaluation Process?
Spending time developing a deeper understanding of each client and his or her home environments
allows therapists to contextualize and make sense
of information gathered during the evaluation. For
example, understanding the value a client places on
furniture and other objects in the home assists the
therapist to acknowledge that they are more than
environmental hazards. It allows them to remain
open and respectful and to anticipate issues where
their evaluation of risk might differ from that of their
client.
Narrative reasoning can often be an automatic
and unconscious process for both novice and expert
therapists. For example, informally observing people
in their homes can reveal a great deal about their
life stories. A well-tended garden informs the therapist that the householder appreciates plants and
that they spend a great deal of time either tending
to the garden themselves or paying someone else
to do it. Photographs on the wall reveal personal
connections. Shelves and floor space cluttered with
valued objects and trinkets alert the therapist to the
attachment that the person has to his or her belongings. These observations are different from the cues
sought in scientific reasoning, where therapists seek
cues to generate and test hypotheses and then filter
information through their scientific knowledge to
analyze or diagnose issues. In narrative reasoning,
the therapist absorbs information from people’s
stories and from the environment to build an understanding of their life experience and the personal
and social culture of the home environment.
What Does It Offer the Client and Therapist?
Narrative reasoning allows clients to examine
their issues and air their concerns in a safe environment. It also enables therapists to develop a deep
understanding of each client’s unique experience
of his or her situation. The trust and rapport developed in this process makes it easier for the client
to disclose personal information and to have faith
in the therapist’s evaluation of the issues because
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it is founded on a deep understanding of the situation. This type of reasoning also allows therapists
to explore the symbolic meaning of home with
the client and to ensure that modifications are life
enhancing, as well as rational and pragmatic. It shifts
the focus from simply addressing issues of safety,
function, and independence to developing a rich and
deep understanding of the person, his or her valued
occupations, and the home environment. It also
affords clients the opportunity to be the authors of
their own life story.
Pragmatic Reasoning
What Is Pragmatic Reasoning?
Pragmatic reasoning is the consideration given
to the practical realities encountered in practice.
It assists therapists to work sensibly and effectively within their own personal resources as well
as within the resources available in the practice
context (Schell, 2014). Therapists bring personal
experiences, professional competencies, and a level
of commitment to professional practice that affect
their capacity to deliver a service. The demands on
therapists’ time within the service and outside work
will also influence their availability. In addition, the
practicalities and logistics of delivering services
within a particular setting (in this case, the home)
and the processes and resources within the service
organization (Schell & Cervero, 1993) influence the
type and level of service that can be delivered.
How Is It Used?
In daily practice, therapists use pragmatic reasoning to make the best use of their personal resources
such as knowledge, skills, abilities, time, and level
of commitment, as well as service resources such
as evaluation resources, structures and processes,
reimbursement schedules, and policy directives.
For example, a therapist might have limited experience in dealing with people like Glenda who have an
increased falls risk, so he or she would dedicate time
prior to the visit to reading about, training in, and
becoming familiar with known falls risks. This would
ensure the most effective use of visit time. If a specific time was allocated for the visit by the service or
reimbursement schedule, the therapist would try to
structure it to ensure that all issues were addressed
and prioritized efficiently. If the service did not
have resources dedicated to assessing falls risk, the
therapist might borrow them from another center
to use in this instance, with plans to order them
for the service should more clients with falls risks
require assistance. The constraints placed on the
evaluation by the client and the environment would
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also need to be considered in order to maximize the
effectiveness of the visit (e.g., advising Glenda of the
length of time required for the visit and negotiating
a mutually convenient time where both the therapist
and Glenda have the necessary time available). If the
environment has many hazards, the therapist might
need to spend more time at Glenda’s house and
postpone the next client visit scheduled for that day
or book a second visit to discuss issues of concern.
How Does It Influence the Evaluation Process?
During the evaluation process, therapists use
their knowledge of and experience with various evaluation strategies to identify and define occupational
performance issues. The diversity of experience and
competency among therapists leads to variability
in the nature and quality of evaluation, especially
in a continually developing area of practice such as
home modification. It is therefore important that, as
a profession, therapists develop and share practice
knowledge and evaluation tools and protocols to
ensure that professional practice and service delivery are consistent and of a high quality. Therapists
with limited experience should consult with more
experienced colleagues to ensure that they have
been effective in identifying all of the relevant issues
in the complex practice environment.
Therapists need to be flexible and responsive to
the specific needs and circumstances of each client
and therefore use pragmatic reasoning to choose the
most appropriate strategies for any given situation.
The home setting presents particular challenges
to traditional evaluation methods and assessment
tools. Being a private space, the client or homeowner might have sensitivities or preferences that
affect which, and how, things can be evaluated. This
requires therapists to search for new evaluation
strategies that accommodate the diversity of issues
and circumstances they encounter in this complex
environment.
The time available for a home visit can also influence the nature of evaluation undertaken. Timelimited or one-off home visits can make it difficult for
therapists to develop a deep understanding of the
person-environment-occupation transaction and to
be entrusted sufficiently to recommend changes to
personal routines and spaces. Consequently, therapists use pragmatic reasoning to assist clients to
prioritize issues to ensure that the most important
matters are attended to in the time available for the
visit.
Service organizations often have a particular
focus and assessment protocols that might or
might not align well with professional practice. In
these situations, therapists fulfill their employment
responsibilities by clarifying what they are able to
offer the client within this service and referring him
or her to other services that can address additional
needs. Therapists can then work with the organization to refine and develop procedures and protocols
within the service so that they are more in line with
current professional knowledge or best practice.
What Does It Offer the Therapist and Client?
Therapists are faced with a considerable number
of pragmatic considerations when undertaking home
modification evaluations. They are acutely aware of
the many factors in the practice context that impinge
on home modification practice and use pragmatic
reasoning to manage the many competing demands
on their time and resources. When managed well,
therapists can optimize the use of their time and
resources to address occupational performance
issues in the home. However, sometimes pragmatic
issues can significantly constrain practice. A focus
on budget, cost-effectiveness, and efficient use of
resources, including therapists’ time, can sometimes
result in an emphasis on throughput and short-term
outcomes. The home is a very personal and private
environment and, as such, sufficient time is required
to allow the therapist to get to know the client and to
allow him or her to focus and direct the evaluation
process. The challenge for therapists is to achieve a
balance between working within available resources
and working long term to maximize the resources available, which includes building the capacity
of therapists and services to respond to people’s
diverse home modification needs. Therefore, pragmatic reasoning necessarily requires therapists to
provide ongoing input to facilitate the development
of service policies, procedures, and resources to
ensure that home modification services are as effective as they are efficient.
Ethical Reasoning
What Is Ethical Reasoning?
Ethical reasoning, often the culmination of the
reasoning process, identifies “what should be done”
from possibilities generated from other reasoning
forms (Schell, 2014). When the art and science of
occupational therapy meet reality, therapists call on
their personal and professional values to ensure that
quality services are delivered to all clients. Ethical
reasoning is the thinking that therapists undertake
to synthesize knowledge and evidence, client values
and goals, an appraisal of his or her competencies,
and practical aspects of service delivery to provide
the best possible care (Radomski, 2008). When
dealing with the many competing forces that affect
Evaluating Clients’ Home Modification Needs and Priorities
their thinking and decision making, therapists filter
decisions through the core values and attitudes of
the profession and its code of ethics. The profession
holds a number of enduring values, one of which is
that all humans are unique. This value challenges
therapists to appreciate each individual’s experiences, values, and goals over theoretical understandings and routine procedures and implores
them to make time and use evaluation strategies that
recognize and understand each person’s distinctive
nature.
How Is It Used?
When considering scientific, narrative, and pragmatic aspects of practice, therapists are often confronted with conflicting information and demands.
Ethical reasoning requires therapists to critically reflect on competing perspectives to ensure
that their actions manifest ethical practice. The
Occupational Therapy Code of Ethics of the AOTA
identifies six Principles and Standards of Conduct,
which require therapists to:
1. Demonstrate a concern for the well-being
and safety of the recipients of their services
(beneficence)
2. Refrain from actions
(nonmaleficence)
that
cause
harm
3. Respect the right of the individual to self-determination, privacy, confidentiality, and consent
(autonomy)
4. Promote fairness and objectivity in the provision of occupational therapy services (justice)
5. Provide comprehensive, accurate, and objective information when representing the profession (veracity)
6. Treat clients, colleagues, and other professionals with respect, fairness, discretion, and integrity (fidelity; AOTA, 2015, pp. 2-8).
When visiting clients’ homes, therapists are privy
to a great deal of information about their clients. For
example, on entering Glenda’s home, the therapist
becomes aware of a number of hazards that put her
at a high risk of falling. Ethical reasoning alerts the
therapist to his or her responsibility to address each
of these before leaving the home. The therapist is
also aware that he or she should not introduce any
additional risks by placing equipment in Glenda’s
path or asking her to perform an activity that would
unnecessarily place her at risk. At the same time, the
therapist has to respect Glenda’s right to privacy and
control in her own home and can therefore not enter
rooms without permission or impose solutions that
are not welcomed. Additionally, the therapist must
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not disclose information to others about Glenda and
her living situation without her permission. Ethical
reasoning also impels the therapist to provide a high
quality of service to all clients, regardless of race,
social circumstances, or attitude, and ensures that
clients are well informed about what can and cannot
be provided by the particular service. The therapist
would also ensure that Glenda is referred to more
appropriate services should her needs fall outside of
his or her responsibilities.
How Does It Influence the Evaluation Process?
It is not uncommon that the values of therapists
or service organizations sometimes differ from those
of clients. These conflicts are inevitable and require
the therapist to use sound reasoning to resolve differences of opinion. Respectful and open discussion
with the client ensures that the therapist understands his or her perspective and collaborates to
achieve a mutually satisfying outcome. Therapists
also need to critically reflect on their personal and
professional values in order to “confront, understand
and work toward resolving the contradictions within
his/her practice between what is desirable and actual practice” (Johns, 2000, p. 34). An evaluation with
sound ethical reasoning ensures that the therapist
evaluates the right things using the best possible
approach for the particular situation, regardless of
the challenges presented. Further information on
frameworks for ethical decision making is provided
in Chapter 12.
What Does It Offer the Therapist and Client?
Ethical reasoning provides the therapist with a
systematic way of addressing conflicts between what
should be done and what can be done (Doherty,
2009). It also ensures that all clients are treated
respectfully and receive high-quality service, regardless of the situation. Within the evaluation process, ethical reasoning allows the therapist to fully
explore the client’s perspective and work collaboratively with them to define and prioritize issues.
Interactive Reasoning
What Is Interactive Reasoning?
The therapeutic relationship, defined as “a trusting connection and rapport established between
therapist and client through collaboration, communication, therapist empathy and mutual understanding and respect” (Cole & McLean, 2003, p. 33-34), is
an essential element of occupational therapy practice. The importance of this relationship between
therapist and client has been well established as
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influential for the outcomes of therapy, such that
without the relationship, interventions may be compromised (Bonsaksen, Vøllestad, & Taylor, 2013).
To this end it is critical to success that the therapeutic relationship or alliance is established and
maintained until goals are achieved (Tickle-Degnen,
2002). Interactive reasoning is “thinking directed
toward building positive interpersonal relationships,
permitting collaborative problem identification and
problem solving” (Schell, 2014, p. 389). Schell states
that it largely involves automatic acts that influence
and form the interpersonal behaviors and communication skills used by the therapist in the creation
and maintenance of a therapeutic relationship in
which occupational therapy can take place with a client. It might be conscious when the therapist thinks
specifically about the relationship, such as supporting a client when he or she is thinking through the
challenges to day-to-day function in the home.
How Is It Used?
In order to build trust, a foundational basis of the
therapeutic relationship, the therapist must enter
the client’s life world (Crepeau, 1991) and employ
strategies that are designed to engage and encourage the client (Schell, 2014). To successfully achieve
this, the therapist must use interactive reasoning
to choose, enact, understand, and account for the
range of automatic and conscious interpersonal and
communicative skills employed to establish and
foster a connection with the client. This enables the
therapist to make best use of communication strategies that the client responds to positively (Schell,
2014). Further, this reasoning is necessary in order
to preserve the therapeutic relationship and enable
the client and therapist to work in collaboration
toward the resolution of performance problems and
achievement of occupational goals (Schell, 2014).
Due to the importance of the therapeutic relationship to the success of occupational therapy
outcomes, interactive reasoning is vital, and therapists need to ensure that they consider and attend
to communicative and behavioral choices that they
implement when working with a client. For example,
when conducting the initial evaluation with Glenda,
the therapist may choose to use an open body position, active listening skills, paraphrasing, inclusion
of clarifying questions, etc. that demonstrate that
he or she is eager to hear about the Glenda’s needs,
priorities, and concerns and to understand the
situation from her perspective. These choices are
made to convey to Glenda that the therapist is open
to working together and will assist in establishing
rapport and the base of trust on which an effective
therapeutic relationship can be built.
Although some of the outcomes of interactive
reasoning, such as the communication skill choices
mentioned, are conscious and easily identified, some
are a result of more automatic acts (Schell, 2014).
Therapists need to work at becoming aware of
their more unconscious tendencies, as these, too,
can affect the therapeutic relationship. An example
might be if a therapist automatically touches Glenda
on the arm to convey sympathy when she mentions
that her husband is deceased, which, depending on
Glenda’s preferences, she might find comforting or
intrusive. Due to the presence of both more conscious and automatic influences, it can at times be
easiest to see the significance of interactive reasoning when an error in reasoning occurs and negatively
affects the therapeutic relationship (Schell, 2014).
Despite this, it is an essential aspect of professional
reasoning requiring attention, as it underpins the
therapeutic relationship, which enables the collaboration and sharing of information between client and
therapist that are necessary for the other reasoning
types.
How Does It Influence the Evaluation Process?
Interactive reasoning, as previously mentioned,
enables the development and continuation of the
therapeutic relationship, which is central to the
occupational therapy process and vital to the successful outcomes of interventions. If a strong and
allied relationship that is focused on working with
the client is not established or maintained, it can
jeopardize all aspects of the occupational therapy
process, including the gathering of information,
therapist understanding of client needs and priorities, establishing goals, professional reasoning, etc.,
as well as associated interventions and outcomes.
In order to obtain and understand the information
on which the other reasonings are based, interactive reasoning is necessary to ensure a relationship
between the therapist and client that enables collaboration and two-way communication. In addition,
if there are problems within or a breakdown of the
therapeutic relationship, interactive reasoning can
be utilized to examine communication skills or interpersonal behaviors, identify potential difficulties/
issues, and enable the therapist to improve upon
or rebuild the therapy relationship or, if necessary,
refer the client on to another therapist or service.
What Does It Offer the Therapist and Client?
Interactive reasoning draws the therapist’s attention to the importance of the therapeutic relationship to ensure successful outcomes in occupational
therapy practice. It provides a means to review the
communication skills and interpersonal behaviors
that are used to establish and maintain a trust-based
Evaluating Clients’ Home Modification Needs and Priorities
relationship that enables collaboration and facilitates ongoing therapy with a client. It also provides
the therapist with a course of inquiry and action if
there are difficulties within the therapeutic relationship that are hindering the occupational therapy
process. It ensures that the client is afforded the
opportunity to be a valued partner in the therapeutic relationship. This enables them to be understood
as a person; their needs, preferences, priorities, and
concerns to be heard; and therapy to be carried out
in an environment where they are respected and
approached with empathy. The successful use of
interactive reasoning contributes to the establishment of a solid alliance between therapist and client,
which enhances the potential for the best possible
outcome(s) from therapy and can be beneficial to
both client and therapist alike. A good relationship
builds client trust, whereby they feel listened to,
thus enabling them to have confidence that the recommendations will address their needs and improve
their circumstances.
TYPES
OF
EVALUATION STRATEGIES
Therapists use a range of evaluation strategies,
such as informal and structured interviews, skilled
observation, and standardized assessments, to gather information about the client and his or her home
and to test hypotheses.
Informal Interview
Home modification evaluations generally begin
with the therapist engaging in an informal discussion
with the client about the home, the reason for referral, or concerns the client has about his or her occupational performance. Interviewing is an essential
step in the evaluation process and generally serves
a dual purpose. First, interviews allow therapists to
gather information; hear clients’ stories; and understand their experiences, concerns, goals, and aspirations (Henry & Kramer, 2009). Second, interviews
afford therapists an opportunity to build collaborative relationships with their clients and gain their
trust (Henry & Kramer, 2009). Interviewing is used
by therapists to create a shared understanding of
each client’s situation so that the home modification
process can address his or her individual concerns
and priorities.
Informal interviews are useful in gathering qualitative information about the client and the home,
which is essential in providing a client-focused
service. These interviews can be unstructured and/
or semistructured but generally take the form of
a conversation, where questions are asked and
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information is provided without adhering to a predetermined format. This two-way communication is
commonly guided by broad goals or, at most, a set
of prompts that direct therapists through a range
of topics. However, to explore issues further, therapists often develop additional questions in response
to the client’s comments or responses. This style
of questioning is used at the start of the visit to
explore clients’ priorities and aspirations and then
throughout the visit as they move through the home
and demonstrate performance in specific areas to
gather further insights into clients’ concerns and
experiences.
Although individual therapists are likely to have
their own personal style of communication, a range
of strategies can be used to increase the effectiveness of informal interviews. At the outset, it is essential to create a safe and accepting interpersonal climate for the interview. Finding a quiet, comfortable
place in the house where the client and therapist
can sit close to each other (3- to 4-ft apart and at
right angles) is an important first step. It is equally
important, however, that the therapist allows the
initial conversation to flow freely while both parties
are settling into the interview and becoming comfortable with each other. It can be valuable to let the
client raise the topic of conversation, because the
therapist can learn more about the client and what
he or she feels is important. This also provides the
therapist with an opportunity to demonstrate genuine interest in the client’s concerns and value his or
her perspective.
Once the interview climate has been established,
the therapist uses a range of questioning techniques,
such as open and closed questions and probing, to
encourage discussion and to explore occupational
performance issues in greater depth. Regardless of
the quality of the interview questions, therapists
need to constantly monitor the effectiveness of
each interview and the quality of the information
acquired. Informal interviews are difficult to conduct
without a lot of experience; however, they are likely
to be most effective when the interviewer:
Ô Is knowledgeable about the content of the
interview
Ô Structures a purposeful and well-rounded
interview
Ô Is open and responsive to topics introduced by
the interviewee
Ô Uses clear communication that can be understood by everyone involved in the interview
Ô Employs a gentle approach that allows the
interviewees sufficient time to consider their
responses and reply
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Chapter 6
Ô Is empathetic and listens attentively to what is
being said, how it is said, and what is not said
Ô Has sensitive responses to the interviewees’
expressed opinions and concerns
Ô Is able to take positive control of the direction
of the interview or steer the interview, based
on agreed goals for the interaction
Ô Is able to critique or challenge what is said if
inconsistencies occur or issues require closer
examination
Ô Remembers what has been said previously and
relates back to information obtained at different parts of the interview
Ô Clarifies information gained and explores the
client’s perceptions of events without imposing meaning or overinterpreting information
(Kvale, 1996)
Informal interviews allow clients to provide therapists with a wealth of information at their own pace;
however, this information can be easily overlooked
or lost if it is not adequately managed or recorded.
However, when utilized effectively, these types of
interviews enable therapists to explore, probe, and
analyze the nature of difficulties clients are experiencing. It takes time and experience to learn to
use informal interviewing well because it can be
difficult to obtain the right information and integrate the information provided, especially when
clients are eager to talk about a broad range of topics. Equally, it can take a great deal of skill to coax
reserved clients to disclose personal information,
which is often required in home modification practice. Experienced therapists who have developed an
internalized framework and procedure for interviewing are comfortably placed to use informal interviewing well. However, without a systematic approach
and regular review, informal interviewing can result
in some issues being explored haphazardly or being
neglected altogether.
Informal interviewing generally allows therapists
to learn a great deal about clients’ particular concerns and requirements and the impact of occupational performance difficulties. Although this information is invaluable in shaping decision making and
negotiations with clients, it is often not recorded formally. This lack of documentation results in “underground practice” (Mattingly & Fleming, 1994; Pierre,
2001), where discrepancies occur between what
therapists do and what they record. Consequently,
the complexity of issues considered when making
home modification decisions is often not acknowledged and documented by therapists or recognized
within services. Even if this qualitative information
was effectively recorded, it is not in a form that
readily allows the outcomes of home modification
interventions to be measured. With the growing
focus on evidence-based practice, therapists need
to ensure that the client’s perspective, which occupational therapy claims to be vital, is recorded. It is
crucial that this perspective is not lost in the search
for standardized evaluation tools in determining the
nature and extent of need and quantifying the effectiveness of interventions.
Structured Interviews and
Checklists
Many occupational therapy services develop
structured forms and checklists that are targeted
at identifying occupational performance issues in
the home for a particular client group. In clinical
practice, these are frequently used to screen for
the presence/absence of occupational performance
issues and to establish the extent and urgency of
the concerns. These forms provide therapists with
a structure for collecting demographic information,
health and/or disability history, roles and routines,
and self-reported ability and support required to
undertake personal and instrumental activities of
daily living (ADLs). In organizations that offer home
modification services, information is also gathered
on the age, materials, structure, design, layout and
features of the house, and the surrounding environment. A number of environmental checklists can
assist therapists to identify environmental features
that are potential hazards or barriers to people with
specific impairments or health conditions. These
tools are a useful guide for therapists who are new
to the service or area of practice because they help
them collect all information relevant to the particular service. With the many distractions that can
occur in a home environment, these tools can ensure
that therapists address everything on the form during the interview or environmental inspection. The
structure of these tools ensures some consistency in
the information gathered and makes it easier when
clients are transferred to other therapists within the
service or revisit the service at a later date. Although
these tools are not standardized and do not often
provide the quantitative information required for
evaluating the effectiveness of an intervention, they
do provide information on the preintervention situation. When clients or other staff view the information collected using these tools, the domain of concern of occupational therapy becomes immediately
apparent.
Evaluating Clients’ Home Modification Needs and Priorities
Although structured forms and checklists are
useful, they do have a number of limitations. It has
been said that “what occupational therapists do
looks simple, what they know is quite complex”
(Mattingly & Fleming, 1994, p. 24). The use of set
forms to ensure consistent information gathering
often oversimplifies what occupational therapists
really do. Two-dimensional information about the
person, activity performance, or the environment
belies the complexity of the person-environmentoccupation transaction. Often, these forms and
checklists do not reflect the breadth and depth of
information that therapists gain when interviewing
clients, which misrepresents the nature of information therapists operate from. Second, once a form
has been developed, it is often assumed that anyone
could collect the information, which leads to services sometimes questioning why other staff could
not be trained to do a home assessment. Third,
in the interest of comprehensiveness, these forms
frequently require therapists to collect additional
nonspecified information to address the specific
concerns of the client at the time of the interview.
This may result in an unnecessary invasion of the
person’s privacy, especially when information about
irrelevant medical conditions is collected or spaces
in the house are inspected unnecessarily. Finally,
these tools are often not reviewed regularly enough
in light of new evidence, theoretical knowledge, or
changes in service practice, which results in traditional practices often persisting well beyond their
use-by date.
Skilled Observations and
Occupational Analysis
Observing clients in their homes, where they perform their usual daily activities, provides a wealth
of valuable information more comprehensive and
detailed than can be gained from interviewing alone.
During the course of the home visit, occupational
therapists observe clients as they move and perform
various activities around the home (e.g., answering
the door, moving through the home, completing
transfers, and making refreshments). These general
observations, often automatic to experienced therapists, provide a basis for discussing the impact of
the health condition or impairment on life within the
home. However, therapists also ask clients to perform specific occupations, in particular, those identified as problematic, during the initial interview. By
skillfully observing occupational performance, therapists can observe behavior in its natural environment and identify factors that are either contributing
to or interfering with performance (Dunn, 2000).
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Occupational therapists have specialized knowledge and skills that allow them to analyze and evaluate occupational performance (Dunn, 2000), and they
use different theoretical lenses to understand occupational performance and factors that contribute to
performance difficulties (Crepeau, Schell, Gillen, &
Scaffa, 2014). For example, when using an ecological
model such as person-environment-occupation or
person-environment-occupation-performance, therapists focus on analyzing the fit between the person,
the occupation, and the environment. Occupational
therapists also use their skills in occupational and
activity analysis to identify the important elements
of various occupations in the home and where and
how breakdowns in performance occur.
Occupational Analysis
Occupational analysis is core to occupational
therapy practice. It allows therapists to analyze occupations of value and concern to clients in the actual
context in which they are performed and to gain an
understanding of their possible meaning, component tasks, specific performance requirements, and
potential facilitators and barriers to performance
(Crepeau et al., 2014). This qualitative information
allows therapists to identify the particular aspects
of the task that result in difficulties or compromise.
Using whole-body reasoning, therapists then examine aspects of the individual’s performance, occupational, and/or environmental demands that are
impinging on successful completion. This type of
analysis acknowledges the unique meaning and purpose of the activity for the individual and recognizes
the distinctive way tasks are performed, depending
on the purpose of the task, the experience and preferences of the person, and the demands and structure of the occupation and environment.
Activity analysis, on the other hand, analyzes
activities in a more abstract sense so as to assist
therapists in anticipating potential difficulties in performance (Crepeau et al., 2014). When undertaking
an activity analysis, therapists tend to identify common components of the task and capacities and environmental elements required for successful completion. This alerts therapists to the specific aspects of
the task where breakdowns in performance are likely
and helps them to understand possible contributions to difficulties and errors. For example, a simple
activity such as going to the toilet incorporates a
number of tasks, and there can be a breakdown at
any stage of this activity if there is a poor personenvironment-occupation fit. Table 6-1 details the
procedural component tasks of going to the toilet.
Task breakdown can occur if the person has specific impairments that make it difficult to anticipate
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Chapter 6
Table 6-1. Activity Analysis of Going to the Toilet
Register need to go to the toilet
Locate and find way to toilet
Open the door
Enter the room
Turn on the light
Close the door
Travel, turn, and position at front of pedestal
Undress
Sit down onto toilet
Reach for toilet paper/release sheet
Transfer weight for wiping
Attend to personal hygiene
Move from sitting to standing
Don and adjust clothing
Turn and flush toilet
Clean toilet bowl
Open door
Negotiate doorway
Find way to sink to wash hands
Turn on faucets
Wash hands
Dry hands
Turn lights on and off at night
Note potential for collapse or assistance need
a toileting need, mobilize to the toilet, locate the
toilet, see various fixtures and fittings, and use
the toilet. In addition, there may be aspects of the
environment that make it difficult for the person
to carry out the activity (e.g., too great a distance,
convoluted or obstructed path of travel, unfamiliar toileting environment, high positioning of door
handles and locks, unfamiliar or inaccessible positioning of light fittings, low toilet pan, inoperable
flush button, hard-to-reach or difficult-to-tear toilet
paper, or lack of space between the entry door and
toilet bowl). Therapists commonly observe people
performing various aspects of activities and analyze
performance difficulties as they occur. This is not a
formalized process but rather one where each therapist uses an individual approach to analyzing tasks
and interpreting problems.
Some standardized tools, such as the Performance
Assessment of Self-Care Skills (PASS; Rogers &
Holm, 1994; Rogers, Holm, & Chisholm, 2016) and
Comprehensive Assessment and Solution Process for
Aging Residents (CASPAR; Sanford, Pynoos, Tejral, &
Browne, 2002), provide a framework for analyzing
and evaluating various household activities. These
tools present essential task elements and a structure
for examining and recording difficulties experienced
and assistance required for successful completion.
Although this type of analysis provides a foundation
for identifying potential performance breakdowns
and contributing factors, these and other activity
analysis frameworks tend to focus on the physical
and immediately observable aspects of activities.
Less attention is paid to the sensory, cognitive, and
emotional demands of activities: preparing for, initiating, and terminating activities and the routines
and habits required when undertaking daily tasks in
the home. There needs to be further evaluation to
determine when, where, and how people undertake
tasks, their experience of the performance, and the
specific qualities of performance that are important
to them.
Therapists generally use a combination of activity
and occupational analysis when observing occupational performance in the home (Crepeau et al.,
2014). Using a blended approach to analysis allows
therapists to understand the particular importance
and issues for specific clients, as well as the factors contributing to performance difficulties and
how these can be addressed (Crepeau et al., 2014).
Because skilled observation is generally undertaken
qualitatively, it can be difficult to measure changes
in performance objectively. The nature and quality
of analysis are also dependent on the therapist’s
clinical experience. Furthermore, it is important to
be aware that an individual’s performance is likely to
vary throughout the day as his or her capacities and
environmental conditions change, and therapists
need to account for this variability when evaluating
an individual’s performance in various household
activities.
Rogers and Holm (2009) have identified a number
of parameters that therapists examine when analyzing occupational performance: value, independence,
adequacy, and safety.
Value
Value is the importance or significance of the
occupation to the individual. When resources are
limited, people generally establish priorities and
reserve their energies for highly valued occupations
(Rogers & Holm, 2009). The relative value of tasks is
often addressed in the interview or other assessment
processes and assists in identifying client goals and
priorities. However, the therapist may review and
revise these priorities in collaboration with the client if further performance concerns become evident
while activities are being performed.
Evaluating Clients’ Home Modification Needs and Priorities
Independence
Independence generally refers to a person’s ability
to complete activities without assistance. A person’s
level of dependence is measured in terms of the type
of assistance he or she requires to complete an activity. Assistance is commonly assessed as progressing from low levels of support, in the form of using
assistive devices and the need for supervision or
task setup, to high levels of support, such as another
person providing verbal or physical prompting or
physical assistance. People’s confidence in their
ability to perform activities in the home is another
facet of independence (Rogers & Holm, 2009). If they
believe they cannot perform a task, it is likely that
their performance will be compromised. Though
independence is the primary goal of many services
and therapists, it may not be important to the client.
Some people with a disability prefer to receive assistance with routine daily living tasks to allow time and
energy for activities they prefer, such as working or
spending quality time with loved ones (Baum, Bass,
& Christiansen, 2005). Sacrificing independence in
one activity can result in more autonomy in overall
lifestyle and a greater quality of life.
Adequacy
Adequacy refers to the efficiency and acceptability of the process and outcome of the activity (Rogers
& Holm, 2009). Efficiency refers to minimizing the
amount of effort required to achieve a given outcome. Rogers and Holm (2009) evaluate efficiency by
examining the degree of difficulty, pain, fatigue, and
dyspnea exhibited or experienced during the task as
well as the amount of time taken. Acceptability of the
outcome is evaluated in terms of social standards,
personal satisfaction, and presence of aberrant
behaviors (Rogers & Holm, 2009).
The ease and comfort with which an individual
undertakes activities are important considerations
when analyzing occupational performance because
they affect his or her personal experience of daily
life within the home, which can subsequently influence overall quality of life. Therapists generally
gather information about the experience of the performance from clients, informally asking whether
they experience any difficulty, pain, fatigue, and
dyspnea during performance. Therapists can also
obtain information on the level of difficulty or discomfort experienced by using standardized tools
such as the following:
Ô The Usability Rating Scale (Pitrella & Kappler,
1988; Steinfeld & Danford, 1997): A 7-point bipolar measure of difficulty ranging from -3 (very
difficult) to +3 (very easy), with 0 providing a
neutral point at the center of the scale
125
Ô The Brief Pain Inventory (Cleeland & Ryan,
1994): A measure of the intensity and interference of pain
Ô The Faces Pain Scale/The Faces Pain Scale—
Revised (Bieri, Reeve, Champion, Addicoat, &
Ziegler, 1990; Hicks, von Baeyer, Spafford, Van
Korlaar, & Goodenough, 2001): A picture scale
of pain intensity
Alternatively, therapists can use customized
scales in the form of Likert scales and semantic
differentials or picture scales. Although customized scales might not be standardized, they provide
therapists with a mechanism for identifying and
discussing clients’ experiences of performance and
perceptions of difficulty or discomfort.
A typical 5-level Likert scale is set out as follows:
How difficult is your current showering routine?
1. Very difficult
2. Difficult
3. Neither easy nor difficult
4. Easy
5. Very easy
Semantic differential scales usually feature
descriptive adjectives with opposite meanings at
either end of a scale. For example:
No pain |___|____|____|___| Worst pain imaginable
No difficulty |___|____|____|___| Severe difficulty
Therapists also monitor clients for clinical signs
of exertion (e.g., increased effort, pallor, sweating, or
labored breathing). Tools such as wearable devices
and monitors can also be useful in gauging increased
effort. The duration of activities can be measured
using a stopwatch; however, the ideal time required
for various household tasks is yet to be calculated
and is likely to vary from one person to another
(Rogers & Holm, 2009). It is likely that clients and
their significant others will report whether the time
taken for the activity is acceptable or manageable.
The acceptability of the outcome is determined
by establishing the person’s level of satisfaction
with the end product and comparing the result
with social expectations (Rogers & Holm, 2009).
Overall satisfaction can be evaluated using qualitative comments, customized scales, or a standardized measure such as the Canadian Occupational
Performance Measure (COPM; Law et al., 1998,
2014), or the In-Home Occupational Performance
Evaluation (I-HOPE; Stark, Somerville, & Morris,
2010), which measure the client’s perception of
performance and satisfaction with performance. It
is difficult to clearly define socially acceptable performance. Therapists generally rely on the client’s
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Chapter 6
level of satisfaction but would be concerned when
outcomes vary significantly from social standards
and place an individual at risk of social alienation
from his or her family, friends, and peer group. The
therapist would then discuss with the person his or
her perception of performance to confirm whether
the outcome required improvement. Therapists also
use skilled observation to note behaviors that interfere with the process or outcome and vary greatly
from the way tasks are typically performed, such as
confusion in the order of the procedure, repetitive
checking, inappropriate use of fixtures and fittings,
and impulsive or disruptive behavior. These are then
discussed with the client and significant others.
Safety
In home modification practice, therapists are
routinely required to assess the safety of individuals in their homes. Safety is defined as the level of
risk that individuals are exposed to when they are
performing specific tasks and is a product of the
interaction between the capacity of the individual at
any given moment, the nature of the task he or she
is performing, and the challenges presented by the
environment (Rogers & Holm, 2009). Although safety
is a complex parameter to measure and control for, it
is also critical to the success of the home modification process. If it is not addressed adequately, there
could be potentially catastrophic consequences for
the client.
A risk management framework is a useful structure for evaluating and managing risks in the home
in a logical and systematic manner. Risk management involves developing processes, structures, and
a culture to manage adverse events and optimize
opportunities for safety (Standards Association of
Australia, 2009). It is a recognized process within a
range of settings and is used by a variety of organizations. Risk management is a consultative process
that involves all stakeholders and, in particular, the
person exposed to the risk. This ensures that all
views are considered in identifying and evaluating
risk and that everyone involved has ownership of
the measure to be undertaken to manage the risk.
Risk management in the home is likely to include
consultation with the client and, in many cases, to
extend to the people he or she lives with, family,
health providers, personal assistance providers, and
advocates.
When undertaking a risk management process, it
is important to define the context and determine the
purpose of the risk management activity. The context refers to the internal and external environment
and, in home modification practice, involves understanding the goals and priorities of clients, their
capacities, their social resources, and the physical
environments in which they live. The purpose of
the risk management activity in this setting is to
minimize risk of injury and maximize opportunities
for meaningful activity in the home—two purposes
that sometimes conflict. Negotiations may need to
be undertaken to achieve a balanced plan that meets
the needs and wants of the client. For example, a
client may wish to soak in a bath regularly to relieve
joint pain but may be exposed to a number of risks
getting in and out of the bath. The occupational therapist or the organization for which he or she works
might also be concerned about their duty of care
and potential litigation in relation to the recommendations made. This may lead to risk minimization at
the expense of the client’s quality of life. Therapists
can use a systematic and inclusive approach to risk
management to meet their duty of care while still
allowing clients to take responsibility for the levels
of risk they wish to include in their daily lives. This
process involves identifying, analyzing, evaluating,
managing, monitoring, and reviewing risks.
Identifying Risks
Identifying risks involves establishing which
events are likely to have adverse or uncertain
outcomes. When identifying risk in the home environment, it is necessary to observe the person
performing the relevant tasks in his or her home.
Self-report is not an adequate method of determining risk because people might not always be aware
of potential risks in their home. Neither is a simple
audit of the physical environment sufficient because,
although an audit might identify hazards (i.e., events
or situations that are the source of danger with the
potential to cause harm or injury) it does not determine the degree of risk involved with the hazard.
Risk is the likelihood of harm resulting from exposure to a hazard. Simply auditing the physical environment for hazards does not take into account the
likelihood of exposure to the hazard and the capacities, vulnerabilities, and experience of the person
and how these interact with the environment.
Analyzing Risks
Once the potential hazards have been identified,
it is necessary to develop an understanding of the
level of risk. Analyzing each risk involves all of the
stakeholders making a judgment about the likelihood
of an adverse event occurring and the consequences
of such an event. When determining the level of risk,
the therapist, client, and other relevant stakeholders
need to consider the following:
Ô Frequency: How often the person is exposed to
the hazard
Ô Probability: The probability of an adverse event
occurring
Evaluating Clients’ Home Modification Needs and Priorities
Ô Consequences: The likely consequences of an
adverse event
Ô History: Previous experience of an adverse
event (Pybus, 1996)
In a home evaluation, a qualitative analysis of risk
is undertaken in consultation with the client and
other household members. For example, if we were
to analyze the risk of falling or tripping on the front
stairs, the client and the therapist would need to
determine how often the stairs are used, the chances
of the person tripping or falling, the consequences of
an incident, and whether an incident has occurred
in the past and how often. Levels of risk vary from
one situation to another. For example, the risk would
be low where a fit and agile older person lived in a
dwelling in good repair, rarely used the front stairs,
and had no history of tripping on the stairs. In another situation, where an older person with osteoporosis lived in a house in poor repair, used the stairs
frequently, and had tripped on the stairs previously,
the risk would be high. Even if this person used the
stairs only intermittently (e.g., to collect the mail)
the potential consequences of a fall would warrant
management of the risk. The process of identifying
and discussing the frequency of exposure, probability of an event, likely consequences, and history of
incidents provides a useful structure for therapists
to discuss their concerns and understand the client’s perception of the risk. By affording clients an
opportunity to discuss the frequency of exposure
and history of adverse events, therapists can gain a
deeper understanding of the potential risk.
Evaluating Risks
Once a judgment has been made about the level
of each identified risk, it is then possible to decide
which risks need to be addressed and their order
of priority. In home modifications, the decisions
will need to take into account the level of risk, the
personal priorities of the client, the role of the organization providing the service, and the resources
available for managing the risk.
Managing Risks
In selecting the most appropriate risk management option, therapists generate a range of options
and collaborate with clients and other stakeholders to agree on the most effective and acceptable
solutions. Several risk management strategies are
employed:
Ô Avoiding the risk: In the home, one option for
managing a risk is to avoid that area of the
home or the activity completely. For example,
a person might choose to use another entry
to the house exclusively and avoid the flight of
stairs in need of repair.
127
Ô Reducing the likelihood of the risk: Possibly
the most common is to reduce the likelihood of
an accident by providing modifications, assistive equipment, alternative ways of performing
tasks, or any combination of these strategies.
However, an additional evaluation will then be
required to ensure that additional or different
risks are not being introduced.
Ô Changing the consequences: Changing the consequences to reduce the extent of injury is
another approach. For example, the person
might take medication, wear protective equipment to reduce the risk of fracture, or wear a
personal alarm to call for help.
Ô Sharing the risk: The risk could be shared, for
example, by getting someone else to collect the
mail or enlisting some help in using the stairs.
Ô Retaining the risk: This is a valid choice where
the activity is highly valued by the individual
and other risk management strategies are neither feasible nor acceptable to the client. For
example, people may choose to continue to
use the stairs to collect mail, regardless of
falls risks, because they have done so all their
lives and would not entertain having someone
else do it for them (Standards Association of
Australia, 2009).
Therapists, and the organizations they work for,
might be averse to this last option because of concerns about meeting their duty of care and possible
litigation. However, imposing unacceptable risk-management strategies on the client is counterproductive because they are likely to cause distress and/
or not be used. In these situations, it is imperative
that the therapist works with the client to ensure he
or she fully understands the probability of an event
occurring and the consequences involved. It is also
important that the client is fully informed on how to
manage the risk and knows where to seek further
assistance if required.
Monitoring and Reviewing Risks
It is essential that therapists maintain an ongoing
review of risk management strategies to ensure that
the management plan is sustainable and remains
effective. Factors that affect the probability and
consequences of an outcome will inevitably change
over time and affect the suitability of a strategy.
Therefore, it is important to follow up once a management strategy has been put in place and then
again at regular intervals to ensure it continues to
manage the risk. Alternatively, clients should be
encouraged to contact the service should they feel
that the probability or consequences of a risk have
changed. Outcome measures can be used to monitor
128
Chapter 6
and review the effectiveness of risk management
strategies. For further information on risk management in home modification practice, please refer to
Chapter 5.
Skilled observation allows therapists to analyze
the person-environment-occupation fit and to identify where and how breakdowns are occurring,
which then provides the foundation for developing
successful interventions. This form of evaluation
requires highly developed skills in observation,
occupational analysis, and risk management and is
often difficult for students and inexperienced therapists to use effectively. Because of the complexity of
the information gathered and the qualitative nature
of it, it is difficult to assess the quality of evaluations
undertaken by various therapists and quantify the
effectiveness of interventions. Once again, without
clear documentation of the evaluation undertaken,
the profession is not able to articulate its unique
approach and contribution to service delivery.
Standardized Assessment
The Nature of Standardized Assessment
Standardized assessments, whether qualitative or
quantitative in nature, are developed and tested to
ensure that the information collected is comprehensive, trustworthy or valid, and consistent or reliable.
Trustworthiness is a term used to refer to ensuring the
credibility and quality of qualitative data. For quantitative measures, validity ensures that the tool measures what it is intended to and that there is agreement about what it is measuring; reliability ensures
that the measures are consistent (Magasi, Gohil,
Burghart, & Wallisch, 2017). Standardized assessments ensure effective, systematic, and consistent
information gathering (Law & Baum, 2005). They
provide therapists with a mechanism for appraising
or calculating the magnitude, quantity, or quality of
a particular characteristic or attribute (Law & Baum,
2017). These tools provide a uniform procedure for
administering the assessment by specifying the
conditions, tools, instructions, and questions. Some
standardized assessments are norm referenced,
whereas others are criterion referenced (Dunn,
2017). Norm-referenced tools compare individual
test scores with those of a comparison sample or an
ideal (Dunn, 2017). These tools are useful for diagnosis or screening because they assist the therapist
in determining the extent of impairment or difficulty
and whether performance warrants further investigation. Criterion-referenced assessments are especially useful for occupational therapists because
they measure performance against an identified
standard rather than an “ideal” (Dunn, 2017). These
tools can be used to identify and specify the goals
and needs of individuals and allow therapists to
evaluate the effectiveness of an intervention. When
using standardized tools, it is imperative that therapists understand the focus and purpose of the tool
and select “the most appropriate measure with the
best psychometric properties” (Cooper, Letts, Rigby,
Stewart, & Strong, 2005, p. 316). In home modification practice, assessment tools need to be sensitive
to changes in occupational performance and ensure
that the environment is adequately acknowledged.
Traditional Assessment Tools
The use of standardized assessments can result
in therapists measuring “variables that can be
measured rather than what should be measured”
(Corcoran, 2005, p. 65). Traditionally, occupational
therapists have used a range of standardized tools to
assess clients’ functional capacities, independence
in ADLs, or accessibility or safety of the environment
(Table 6-2). Assessing the functional capacities of an
individual, such as motor (sensorimotor), process or
cognitive, communication, and interaction or social
capacities in a standardized environment assists
therapists in anticipating performance issues or
understanding aspects of the person that are likely
to constrain occupational performance. Establishing
the person’s level of dependence in a range of ADLs
also alerts the therapist to potential occupational
performance concerns in the home environment.
Therapists can develop an awareness of challenges
to occupational performance in the home by using
standardized tools to identify barriers and hazards
in the home environment. Table 6-2 provides an
overview of a range of standardized assessments
available to therapists.
Historically, the person, occupation, and environment have been viewed as discrete elements
that could be assessed independently (Cooper et
al., 2005). However, the interdependent relationship between these elements is increasingly being
acknowledged. Occupational performance is considered to be the result of all three elements working
together and affecting each other. These traditional
assessments tell us little about the person-environment-occupation transaction in the home and how
this affects occupational performance, something
that is considered critical in assessing occupational
performance in this natural environment (Law &
Baum, 2005). They often have a specific purpose and
focus, which make it difficult to address the unique
needs of individual clients, the person’s occupational experience and interests, the specific demands
of the activity, the fit between the person and the
environment, or the capacity of the environment to
support specific occupations (Law & Baum, 2005).
Evaluating Clients’ Home Modification Needs and Priorities
129
Table 6-2. Standardized Measures of Functional Capacity, Independence, Occupational Performance,
and the Environment
FUNCTIONAL CAPACITIES
REFERENCE
Audition Screening Tool
Popelka, G. R. (1997). High and low pitch sounds: A screening tool.
Unpublished manuscript.
Caregiver Strain Index
Robinson, B. C. (1983). Validation of a caregiver strain index. Journal of
Gerontology, 38(3), 344-348.
Modified Caregiver Strain Index
Thorton, M., Travis, S.S. (2003). Analysis of the reliability of the Modified
Caregiver Strain Index. The Journal of Gerontology, Series B, Psychological
Sciences and Social Sciences, 58(2), S129.
Functional Reach Test
Duncan, P. W., Weiner, D. K., Chandler, J., & Studenski, S. (1990). Functional
reach: A new clinical measure of balance. Journal of Gerontology: Medical
Sciences, 45(6), M192-M195.
Geriatric Depression Scale
Yesavage, J. A., Brink, T. L., Rose, T. L., Lum, O., Adey, M., Leirer V.O. (1983).
Development and validation of a geriatric depression screening scale:
A preliminary report. Journal of Psychiatric Research, 17(1), 37-49.
Geriatric Depression Scale: Short Form
Sheikh, J. I, & Yesavage, J.A. (1986). Geriatric Depression Scale (GDS).
Recent evidence and development of a shorter version. In T.L. Brink (Ed.).
Clinical gerontology: A guide to assessment and intervention (pp., 165-173).
New York: The Haworth Press, Inc.
Lighthouse Near Acuity Card
Ferris, F. L., Kassoff, A., Bresnick, G. H., & Bailey, I. (1982). New visual acuity
charts for clinical research. American Journal of Ophthalmology, 94, 91-96.
Lighthouse International Functional Vision Horowitz, A., Teresi, J., & Cassels, L. A. (1991). Development of a vision
Screening Questionnaire
screening questionnaire for older people. Journal of Gerontological Social
Work, 17(3/4), 37-56.
Lighthouse International, 111 East 59th Street, New York, NY, 10022. Tel:
(212) 821-9525, Fax: (212) 821-9706
Mini-Mental State Examination
Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). “Mini-Mental State”:
A practical method for grading cognitive state if patients for the clinician.
Journal of Psychiatric Research, 12, 189-198.
Montreal Cognitive Assessment
www.mocatest.org
Nasreddine, Z. S., Phillips, N. A., Bédirian, V., Charbonneau, S., Whitehead,
V., Collin, I., . . . Chertkow, H. (2005). The Montreal Cognitive Assessment,
MoCA: A brief screening tool for mild cognitive impairment. Journal of the
American Geriatrics Society, 53(4), 695-699.
Patient Health Questionnaire—9
Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PhQ-9: Validity
of a brief depression severity measure. Journal of General Internal Medicine,
16(9), 606-613.
Short Blessed Test
Katzman, R., Brown, T., Fuld, P., Peck, A., Schechter, R., & Schimmell, H.
(1983). Validation of a short orientation-memory-concentration test of cognitive
impairment. American Journal of Psychiatry, 140(5), 734-739.
Timed Up-and-Go Test
Podsiadlo, D., & Richardson, S. (1991). The timed “up-and-go”: A test of basic
mobility for frail elderly persons. Journal of the American Geriatrics Society,
39, 142-148.
Zarit Burden Interview
Zarit, S. H., Reever, K. E., & Bach-Peterson, J. (1980). Relatives of the impaired
elderly, correlates of feeling of burden. Gerontologist, 20(6), 649-655.
Zarit Burden Interview—Revised
Zarit, S. H., Orr, N. K., & Zarit, J. M. (1985). The hidden victims of
Alzheimer’s disease: Families under stress. New York: New York University
Press.
(continued)
130
Chapter 6
Table 6-2. Standardized Measures of Functional Capacity, Independence, Occupational Performance,
and the Environment (continued)
LEVEL OF INDEPENDENCE
REFERENCE
ADL Staircase
Sonn, U., & Hulter-Åsberg, K., (1991). Assessment of activities of daily living in
the elderly. Scandinavian Journal of Rehabilitation Medicine, 23, 193-202.
ADL Staircase—Revised
Iwarsson, S., & Isacsson, Å., (1997). On scaling methodology and environmental influences in disability assessments: The cumulative structure of personal
and instrumental ADL among older adults in a Swedish rural district. Canadian
Journal of Occupational Therapy, 64, 240-251.
Modified Barthel Index
Shah, S., Vanclay, F., & Cooper, B. (1989). Improving the sensitivity of the
Barthel Index for stroke rehabilitation. Journal of Clinical Epidemiology, 42,
703-709.
Functional Independence Measure (FIM) Uniform Data System for Medical Rehabilitation. (2009). The FIM system clinical guide—Version 5.2. Buffalo, NY: UDSMR, State University of New York at
Buffalo.
Katz Index of Activities of Daily Living
Katz, S., Ford, A. B., Moskowitz, R. W., Jackson, B. A., & Jaffe, M. W.
(1963). Studies of illness in the aged: The index of ADL: A standardized measure of biological and psychosocial function. Journal of the American Medical
Association, 185(12), 914-919.
Functional Independence Measure for
Children (WeeFIM)
Msall, M. E., DiGaudio, K., Rogers, B. T., LaForest, S., Catanzaro, N. L.,
Campbell, J., . . . Duffy, L. C. (1994). The Functional Independence Measure
for Children (WeeFIM): Conceptual basis and pilot use in children with developmental disabilities. Clinical Pediatrics, 33(7), 421-430.
OCCUPATIONAL
PERFORMANCE
REFERENCE
COPM
Law, M., Baptiste, S., Carswell, A., McColl, M., Polatajko, H., & Pollock, N.
(2014). Canadian occupational performance measure (5th ed.). Ottawa, ON:
CAOT Publications ACE.
Occupational Circumstances
Forsyth, K., Deshpande, S., Kielhofner, G., Henriksson, C., Haglund, L., Olson,
Assessment—Interview and Rating Scale L., . . . Kulkarni, S. (2005). The Occupational Circumstances Assessment
Interview and Rating Scale (OCAIRS)—Version 4.0. Chicago, IL: Model of
Human Occupation Clearing House, University of Illinois at Chicago.
Occupational Performance History
Interview II (OPHI II)
Kielhofner, G., Mallinson, T., Crawford, D., Nowak, M., Rigby, M., Henry,
A., & Walens, D. (2004). The Occupational Performance History InterviewII—Version 2.1. Chicago, IL: Model of Human Occupation Clearinghouse,
University of Illinois at Chicago.
Occupational Self-Assessment (OSA)
Baron, K., Kielhofner, G., Ienger, A., Goldhammer, V., & Wolenski, J. (2006).
Occupational Self-Assessment—Version 2.2. Chicago, IL: Model of Human
Occupation Clearinghouse, University of Illinois at Chicago.
QUALITY OF PERFORMANCE
REFERENCE
Assessment of Motor and Process Skills
(AMPS)
Fisher, A. G., & Jones, K. B. (2011). Assessment of Motor and Process Skills:
Development, standardization, and administration manual (7th ed. Rev.). Fort
Collins, CO: Three Star Press.
Client-Clinician Assessment Protocol
(C-CAP)
Lilja, M. (2002). Riktlinjer för användning av Client-Clinician Assessment
Protocol (C-CAP). [Guidelines for Using the Client-Clinician Assessment Protocol
(C-CAP)]. Stockholm, Sweden: Karolinska Institutet.
PASS Clinic and PASS Home
Rogers, J. C., Holm, M. B., & Chisholm, D. (2016). The Performance
Assessment of Self-Care Skills (PASS)—Version 4.1. Pittsburgh, PA: University of
Pittsburgh.
(continued)
Evaluating Clients’ Home Modification Needs and Priorities
131
Table 6-2. Standardized Measures of Functional Capacity, Independence, Occupational Performance,
and the Environment (continued)
ACCESSIBILITY, USABILITY, AND REFERENCE
SAFETY OF THE ENVIRONMENT
CASPAR
Sanford, J. A., Pynoos, J., Tejral, A., & Browne, A. (2002). Development of
a comprehensive assessment for delivery of home modifications. Physical &
Occupational Therapy in Geriatrics, 20(2), 43-55.
Dimensions of Home Measure (DOHM)
Aplin, T., Chien, C. W., & Gustafsson, L. (2016). Initial validation of the
dimensions of home measure. Australian Occupational Therapy Journal, 63(1),
47-56.
Home and Community Environment
Kaysor, J., Jette, A., & Haley, S. (2005). Development of the Home and
Community Environment (HACE) instrument. Journal of Rehabilitation Medicine,
37(1), 37-44.
Home Environmental Assessment
Protocol
Gitlin, L. N., Schinfeld, S., Winter, L., Corcoran, M., Boyce, A., & Hauck, W.
(2002). Evaluating home environments of persons with dementia: inter-rater
reliability and validity of the home environmental assessment protocol (HEAP).
Disability and Rehabilitation, 24(1), 59-71.
Home Occupational Environment
Assessment
Baum, C. M., & Edwards, D. F. (1998). Guide for the Home OccupationalEnvironmental Assessment. St. Louis, MO: Washington University Program of
Occupational Therapy.
Home Falls and Accidents Screening
Tool
Mackenzie, L., Byles, J., & Higginbotham, N. (2000). Designing the Home
Falls and Accidents Screening Tool (HOME FAST): Selecting the items. British
Journal of Occupational Therapy, 63(6), 260-269.
Housing Enabler (HE)
Iwarsson, S., & Slaug, B. (2001). The Housing Enabler: An instrument for
assessing and analyzing accessibility problems in housing. Navlinge och
Staffanstorp, Sweden: Veten & Stapen HB & Slaug Data Management.
I-HOPE
Stark, S. L., Somerville, E. K., & Morris, J. C. (2010). In-Home Occupational
Performance Evaluation (I-HOPE). American Journal of Occupational Therapy,
64(4), 580-589.
Safety Assessment of Function and the
Environment for Rehabilitation
Oliver, R., Blathwayt, J., Brackley, C., & Tamaki, T. (1993). Development of the
Safety Assessment of Function and the Environment for Rehabilitation (SAFER)
tool. Canadian Journal of Occupational Therapy, 60(2), 78-82.
Safety Assessment of Function and the
Environment for Rehabilitation—Health
Outcome Measurement and Evaluation
Chiu, T., Oliver, R., Ascott, P., Choo, L., Davis, T., Gaya, A., . . . Letts, L.
(2006). Safety assessment of function and the environment for rehabilitation:
Health outcome measurement and evaluation (SAFER-HOME) version 3 manual. Toronto, ON: COTA Health.
Usability in My Home
Fänge, A., & Iwarsson, S. (1999). Physical housing environment: Development
of a self-assessment instrument. Canadian Journal of Occupational Therapy,
66, 250-260.
Fänge, A. (2002). Usability in My Home manual. Lund, Sweden: Lund
University, Division of Occupational Therapy.
Westmead Home Safety Assessment
Clemson, L. (1997). Home fall hazards. A guide to identifying fall hazards in
the homes of elderly people and an accompaniment to the assessment tool
the Westmead Home Safety Assessment. Victoria, Australia: Co-ordinates
Publications.
132
Chapter 6
Measures of Occupational Performance
There are few standardized assessment tools that
quickly and accurately assess many of the parameters of interest for occupational therapists and their
clients (Corcoran, 2005), in particular, occupational
performance and the person-environment-occupation transaction. When measuring occupational performance, occupational therapists need to capture
both the subjective experience and the objective
performance (McColl & Pollock, 2017). They require
tools that allow them to understand the specific
needs of the individual and assist them to explain
behavior. A number of structured and semistructured interview schedules have been developed that
guide therapists to systematically examine the individual’s experience of occupation (e.g., the COPM
[Law et al., 1998, 2014], OSA [Baron, Kielhofner,
Ienger, Goldhammer, & Wolenski, 2002, 2006], and
the OPHI-II [Kielhofner et al., 1998, 2004]). Whereas
the OPHI-II and the OSA both examine the impact of
the environment on occupational performance, the
COPM focuses primarily on defining occupational
performance issues and relies on the client and
therapist exploring the impact of the environment
on performance through informal discussion and
observation. A detailed description and review of
these tools is available in McColl and Pollock (2017).
These standardized tools allow therapists to develop
an understanding of clients’ past and present experiences and perceptions of their occupational performance and assist in the development of occupationfocused goals (Fasoli, 2008). The client-centered
nature of these tools engages the client in identifying
occupational performance issues, thus increasing
his or her involvement in the evaluation process
and the therapist’s understanding from the client’s
perspective. These tools also allow individualized
intervention plans to be developed and the impact
of these to be evaluated.
Occupational therapists frequently use standardized assessments to assess occupational performance in relation to personal and instrumental
ADLs and community participation. Assessments
of ADLs usually focus on determining the level
of independence across a range of tasks for the
purposes of screening or measuring outcomes
(e.g., the Modified Barthel Index [Shah, Vanclay, &
Cooper, 1989], FIM [Uniform Data System for Medical
Rehabilitation (UDSMR), 1997, 2009], WeeFIM [Msall
et al., 1994], Katz Index of Activities of Daily Living
[Katz, Ford, Moskowitz, Jackson, & Jaffe, 1963],
ADL Staircase [Sonn & Hulter-Åsberg, 1991], and
the ADL Staircase—Revised [Iwarsson & Isacsson,
1997]). Generally, these global measures of independence do not provide information on the quality of
performance or problematic aspects of the tasks
(Gitlin, 2005). Though they may be useful as screening tools, they are not designed to analyze or diagnose occupational performance issues or evaluate
home modification outcomes.
Recently, a number of performance-based assessments have been designed to assist therapists to
objectively analyze the quality of performance and
identify barriers to valued occupations. A detailed
description of assessments of personal and instrumental ADLs and community participation is available in Law et al. (2017). Some of these tools rely
on self or proxy report. However, tools that use
performance observation are of particular interest to home modification therapists because they
allow them to evaluate the quality of occupational
performance in daily activities and the factors that
contribute to this. Tools of particular interest are the
AMPS (Fisher, 1995; Fisher & Jones, 2011a, 2011b) and
PASS (Chisholm, Toto, Raina, Holm, & Rogers, 2014;
Rogers & Holm, 1994). Therapists using these tools
can select tasks relevant to the client in his or her
own environment and diagnose the precise moment
and nature of performance breakdown. They examine the quality of performance rather than focusing
solely on the outcome of performance. The AMPS is
used by therapists who undergo extensive training
to examine an individual’s ability to perform specific
motor and process skills within meaningful personal
and instrumental ADLs selected from a bank of more
than 120 standardized ADL tasks (Fisher & Griswold,
2014). This tool allows therapists to diagnose specific performance difficulties that clients experience
when undertaking activities but does not measure
the impact of the environment or environmental
interventions on performance.
The PASS is one of the few tools that examines
safety and adequacy of performance in addition
to level of independence on a 4-point scale (Gitlin,
2005). The PASS is available in a clinic and home
version, and both include 26 core tasks related
to functional mobility (5), personal self-care (3),
instrumental ADLs with cognitive emphasis (14),
and instrumental ADLs with physical emphasis (4)
(Furphy, & Stav, 2014; Holms, & Rogers, 2017). Each
task is criterion referenced, detailing the subtasks
required for successful completion (Figure 6-1).
Therapists can select specific tasks depending on
the client’s priorities or lifestyle or use the task
development template to develop a new task. The
tool allows therapists to identify the precise point
of task breakdown and to provide verbal support,
nondirective or directive verbal support, gestures,
task and environmental modification, demonstration, physical guidance, physical support, or total
assistance to support task completion.
Evaluating Clients’ Home Modification Needs and Priorities
133
Figure 6-1. Extract from PASS—functional mobility: toilet transfers. (Reprinted with permission from J. C. Rogers and M. B. Holm,
University of Pittsburgh, Pittsburgh, PA.)
134
Chapter 6
The C-CAP (Lilja, 2002; Petersson, Fisher,
Hemmingsson, & Lilja, 2007) uses both self-report
and observation to evaluate an individual’s performance in terms of independence, difficulty, and safety of activities, including mobility (14) and personal
(10) and instrumental (12) ADLs (Thomas Jefferson
University, n.d.). It has four parts: Part I provides
questions to build rapport and explore routines and
support systems. Part II is a client self-report of perceived ability to perform daily life tasks and records
assistive devices currently in use (see extract in
Figure 6-2). Part III examines the client’s readiness to
change, and Part IV consists of occupational therapist observations and rating of the client’s ability to
perform daily life tasks (Petersson et al., 2007). The
tool provides therapists with a structure for exploring the client’s current experience, perceptions of
performance, and readiness to change and setting
goals for home modification interventions.
Environmental Assessments
With the growing recognition of the role of the
environment in disablement, a number of assessments have been developed to examine the environment in relation to the person and his or her
ability to operate effectively in that environment. For
a comprehensive review of quality environmental
measures, refer to Cooper et al. (2005). Cooper et
al. note it is difficult for any one tool to assess this
multifaceted and complex entity comprehensively.
Consequently, it is important to be clear about the
purpose and focus of the tools available and what
each can contribute to an understanding of the
impact of the environment on occupational performance. There are tools designed specifically to
analyze the home environment: the HE (Iwarsson
& Slaug, 2010), Maintaining Seniors’ Independence: A
Guide to Home Adaptations (Canada Mortgage and
Housing Corporation [CMHC], 2012), the CASPAR
(Sanford et al., 2002), the I-HOPE (Stark et al., 2010),
and the DOHM (Aplin et al., 2013).
The HE is based on the Enabler developed by
Steinfeld in the 1980s (Fänge, Risser, & Iwarsson,
2007) and is particularly useful for examining the
congruence between the person’s functional capacities and his or her physical environment. There is
a particular focus on assessing the accessibility
of the home environment for people with a range
of functional and mobility impairments, such as
difficulty interpreting information, severe loss of
sight, complete loss of sight, severe loss of hearing,
prevalence of poor balance, incoordination, limitations of stamina, difficulty in moving head, difficulty
in reaching with arms, difficulty in handling and
fingering, loss of upper extremity skills, difficulty
bending or kneeling, reliance on walking aids, reliance on wheelchair, and extremes of size and weight
(Figure 6-3). This tool (demonstration version available at www.enabler.nu) allows therapists to identify
potential accessibility barriers in the home, which
can then be examined further through additional
performance testing (Cooper et al., 2005).
The HE is administered in three steps:
1. Using a combination of interview and observation, the functional limitations (13 items) and
dependence in mobility (2 items) are identified.
2. The physical barriers in the home and immediate outdoor environment (188 items) are noted.
3. The accessibility score is calculated using a
complex matrix and specialized software to
examine the profile of functional limitations
and mobility dependence against the accessibility barriers in the environment, where a
predefined severity score has been provided
for each barrier. The severity of accessibility
barrier is rated 1 through 4, with higher points
awarded to items that are likely to present
more severe problems to people with that limitation (Figure 6-4). The final score indicates the
magnitude of accessibility problems in the environment. Scores higher than zero indicated the
presence of accessibility problems (Iwarsson &
Slaug, 2010).
Currently, this tool is used to evaluate the suitability of accommodation for people with a range of functional and mobility impairments to assist in municipal planning (Fänge et al., 2007) and in research to
identify the number and magnitude of accessibility
problems in housing for older people and its relationship to healthy aging outcomes (Fänge & Iwarsson,
2005; Iwarsson, 2005; Iwarsson, Horstmann, & Slaug,
2007). Although the accessibility measures in this
tool are based on the Scandinavian accessibility
standards, this tool directs therapists to environmental features that are potential accessibility barriers to people with a range of mobility and functional
impairments.
Maintaining Seniors’ Independence: A Guide to
Home Adaptations (CMHC, 2012) was designed for
occupational therapists to identify:
Ô Self-care and household activities that people
have difficulty completing independently
Ô Obstacles in the home that can impede activities from being undertaken
Ô Home improvements and minor adaptations
that are inexpensive and easy to complete
Evaluating Clients’ Home Modification Needs and Priorities
135
Figure 6-2. Extract from the C-CAP (Gitlin et al., 2006; Lilja, 2002; Petersson, Fisher, Hemmingsson, & Lilja, 2007). (Reprinted with
permission from Laura Gitlin.)
136
Chapter 6
Figure 6-3. HE—functional limitations form. (Reprinted with permission from Iwarsson, S., & Slaug, B. [2010]. The Housing Enabler: A
method for rating/screening and analysing accessibility problems in housing [2nd ed.]. Lund and Staffanstorp, Sweden: Veten & Skapen
HB and Slaug Enabling Development.)
Figure 6-4. HE—environmental assessment form. (Reprinted with permission from Iwarsson, S., & Slaug, B. [2010]. The Housing
Enabler: A method for rating/screening and analysing accessibility problems in housing [2nd ed.]. Lund and Staffanstorp, Sweden: Veten
& Skapen HB and Slaug Enabling Development.)
Evaluating Clients’ Home Modification Needs and Priorities
137
Figure 6-5. Extract from Maintaining Seniors’ Independence: A Guide to Home Adaptations. (Reprinted with permission from Canada
Mortgage and Housing Corporation. [2012]. Maintaining seniors’ independence: A guide to home adaptations. Ottawa, ON: Author.)
The guide uses semistructured interview and
observations of the client undertaking various activities within the home and can take 1 to 2 hours. It
includes 73 items grouped under topics such as
general accessibility; getting up, dressing, and tidying the bedroom; bathing and personal hygiene at
the basin; taking a shower; taking a bath; using the
toilet; preparing meals; doing the laundry; cleaning
the house; using the telephone; enjoying leisure/
doing business; and taking medication. Figure 6-5
shows an extract of items from bathing and personal
hygiene at the basin.
The assessment tool is aimed at working with
older people who are experiencing changes in their
physical autonomy (i.e., the ability to independently
undertake the various ADLs due to motor, organic,
sensory, or speech difficulties). It has not been
designed to meet the particular needs of persons
with mental or major psychological deficiencies
(confusion, perceptual problems). The tool is mostly
intended for people living in apartments and singlefamily homes. The suggested minor adaptations
require the clinical judgment of an occupational
therapist to determine suitability and tailoring to
the specific requirements of the individual, and more
elaborate adaptations require engagement with consultants in architectural design and residential construction (CMHC, 2012).
The CASPAR (Sanford et al., 2002) is a clientdirected assessment that enables an older adult, family, or nonspecialist therapist to identify problems in
undertaking tasks in the home. This tool examines
138
Chapter 6
Figure 6-6. Example of CASPAR item. (Reprinted with permission from Extended Home Living Services, Wheeling, IL.)
the person’s interaction with the specific elements
in the built environment when accessing the house;
mobilizing throughout the house; managing controls
such as lighting and temperature controls; getting in
and out of bed; and undertaking daily living tasks
such as toileting, bathing, grooming, cooking, and
washing. Figure 6-6 provides an extract from the
CASPAR, which examines the use of the bathroom.
The CASPAR allows therapists to record instances
where the client experiences a problem with specific
task elements, receives help, or uses a device for
assistance. This tool provides a useful structure
for documenting problems and prioritizing personenvironment issues but does not allow therapists to
document or record changes in the quality of performance. It does, however, provide detailed diagrams
to guide therapists in measuring specific aspects of
the built environment related to common problems
and modifications.
The I-HOPE is a performance-based measure that
focuses on home-based activities that are essential
for aging in place (Stark et al., 2010). It was developed in response to the author’s identification that
there was an absence of assessments that reviewed
function in relation to the environment. To address
this, this measure was designed to examine the fit
between the person and environment in the home,
encouraging the identification and review of the
effects of “person-environment misfits” (Stark et al.,
2010). While acknowledging the influence of the environment on performance, this measure also considers the client’s perspective on and satisfaction with
their performance in their activity participation and
enables the observation of changes in the personenvironment fit before and after home modification.
This measure enables a trained therapist to establish current activity patterns, ascertain activities
that are difficult but important to the person, and
identify environmental barriers that affect specific
Evaluating Clients’ Home Modification Needs and Priorities
139
Figure 6-7. The I-HOPE process.
activities. It achieves this by using a three-step process, including (Figure 6-7):
1. An activity card sort in which 44 activities are
sorted into five categories: (1) I do not do/do
not want to do; (2) I do now with no problem;
(3) I do now with difficulty; (4) I do not do but
wish to do; and (5) I am worried about doing in
the future
2. Client ranking of problematic activities to measure subjective performance and associated
satisfaction with performance on a 5-point scale
3. Therapist observation of client performing
activities in the relevant environmental context to enable identification of environmental
barriers. Therapists then rate the impact of the
barriers on performance on a 6-point scale,
with 0 = independent with or without a device,
1 = standby assistance/independent with difficulty/unsafe, 2 = minimal assistance, 3 = moderate assistance, 4 = maximum assistance, and
5 = no activity.
From the completion of this assessment process,
four subscales are derived, including an activity
participation score, client’s rating of performance
score, client’s satisfaction with performance score,
and severity of environmental barriers score (Stark
et al., 2010).
The I-HOPE demonstrates sound psychometric
properties and enables therapists to reliably determine a client’s participation in daily activities, ability to perform activities, satisfaction with their
performance, and the influence of environmental
barriers on activity performance (Stark et al., 2010).
This tool was designed for older adults (60 years
and older) and may not be generalizable because the
designated activities may not be applicable to other
populations. Furthermore, it is limited to evaluating
clients in their current environment, as the client
must be present at the time of assessment. Despite
this, the I-HOPE appears to be clinically useful and
encourages the follow-up and review of outcomes
postmodification as it has the potential for measuring change in performance, satisfaction, and environmental barrier scores between preintervention
and postintervention.
As home modification practice becomes more
person-centered, occupational therapists want to
understand the dimensions of home that influence
decision making and ensure that modifications are
not negatively affecting the experience of home. The
DOHM, based on a literature review and an extensive
qualitative study (Aplin, de Jonge, & Gustafsson,
2013, 2015), was developed to examine the six dimensions of home that are important considerations
in the home modification process and that can be
affected by changes to the home environment. The
DOHM is a self-report tool that consists of 36 items
(Table 6-3) measuring various dimensions of home:
personal (11 items), social (4 items), occupational (5
items), temporal (3 items), physical (12 items), and
societal (a single item measuring clients’ comfort
with the cost of the modifications; Aplin, Chien,
& Gustafsson, 2016). Each statement is related to
aspects of each dimension (see Table 6-3) and is
rated on a progressive 5-point Likert scale, with
response descriptors being 1 = strongly disagree,
2 = disagree, 3 = unsure, 4 = agree, and 5 = strongly
agree (Aplin et al., 2016).
Although still early in its development, the DOHM
has established content validity following a review
by six expert occupational therapists and academics, who rated the tool as being comprehensive in its
overall measurement of the dimensions of home with
inter-rater agreement of 0.83 (Aplin et al., 2013). The
unidimensionality of the DOHM’s subscales has been
140
Chapter 6
Table 6-3. Dimensions of Home Measure (DOHM) Items
PERSONAL DIMENSION: PRIVACY, SAFETY, AND FREEDOM
•
•
•
•
•
•
•
I have the privacy I want from others in my home.
I have enough privacy from neighbors and other people in the street.
I feel safe living in this home.
I feel safe while moving around and doing activities in and around my home.
I feel independent that I am able to do the things I want to myself.
My home allows me to get out as much as I want.
I can be myself at home.
PERSONAL DIMENSION: IDENTITY AND CONNECTEDNESS
•
•
•
•
I am happy with the appearance of my home.
My home reflects who I am.
I feel connected to my home.
My home contains special memories for me.
SOCIAL DIMENSION: FAMILY AND FRIENDS
•
•
•
•
I can easily have friends and family visit if I want.
I have good relationships with those I live with or who visit often.
The modifications will/do suit others who use my home.
It is easy for me to do activities with my friends and family at my home.
OCCUPATIONAL DIMENSION: HOME AS A PLACE OF ACTIVITIES
•
•
•
•
•
My home is easy to clean.
I can easily move around in my home.
I can easily do the activities I need to in my home (e.g., shower, toilet).
I can easily do the activities I enjoy at home (e.g., leisure activities).
It is easy for my carers to help me with the activities for which I need help.
TEMPORAL DIMENSION: HOME NOW AND IN THE FUTURE
• I am happy with my daily/weekly routine at home.
• I know where everything is and how it works in my home.
• With how things are at the moment, I am well set up for the future in my home.
PHYSICAL DIMENSION: STRUCTURE, SERVICES, AND FACILITIES
•
•
•
•
•
•
The wiring in my home is in a good condition.
The ventilation in my home is in good working order.
The plumbing in my home is in good working order (e.g., drainage in the bathroom).
I am happy with the layout of my home.
My home has no structural problems.
The materials and finishes in my home are in good condition (e.g., the flooring, taps, sink, and tiles).
PHYSICAL DIMENSION: AMBIENCE AND SPACE
•
•
•
•
•
•
I enjoy the ambience of my home (e.g., a view, breeze, or sunshine).
I can easily keep warm/cool enough in my home.
I have enough space in my home for my needs.
I have enough storage space in my home.
I have good light in my home.
When coming and going from my home, I am protected from the weather.
SOCIETAL DIMENSION: COST
• I am comfortable with the cost of the modifications (e.g., initial installation costs, maintenance).
Evaluating Clients’ Home Modification Needs and Priorities
supported by Rasch-based principal component
analysis and item-fit analysis. Hierarchical results of
item difficulties, however, revealed that more items
would be needed to capture the full range of a participant’s experiences of home (Aplin et al., 2016).
Selecting and Evaluating Standardized
Assessment Tools
When choosing an assessment tool, it is critical
to understand the purpose and focus of the tool and
to ensure that these align with the intended application (Cooper et al., 2005). Unfortunately, there
are few tools that address the issues of concern of
occupational therapists and their clients and assess
them in the way they need to be assessed. Once
a suitable standardized tool has been identified,
therapists investigate the psychometric properties
of the tool to ensure that it has adequate validity,
reliability, sensitivity for its purpose and clinical
utility for use in home modification practice. Using
valid and reliable measures allows therapists to
determine the extent of the problem and evaluate
the effectiveness of interventions in addressing
them. Standardized evaluation tools ensure consistency and assist those therapists with limited experience to identify and address issues thoroughly and
systematically. However, standardized tools may
have limited flexibility when used to address clients’
specific concerns; the complex interaction between
the person, environment, and occupations; and the
unique situations encountered in home environments. It is often challenging to use standardized
tools effectively in the home because time is often
limited, and it is difficult to follow instructions rigidly in an unfamiliar and unstructured environment
(Gitlin, 2005). Some tools require specialist training
and have specific setup requirements. Many standardized measures are not sensitive to the changes
that can result from interventions, such as decrease
in time taken and making the client feel safer, and
can penalize the use of standard interventions, such
as the use of an assistive device. These limit their
usefulness in evaluating outcomes. For example,
the FIM (UDSMR, 1997, 2009) is considered a gold
standard in terms of its psychometric properties.
While it may be a useful tool for screening level of
independence, it does not provide therapists with
useful information about the adequacy and safety of
performance or the person-environment-occupation
transaction, and it is not responsive to changes
resulting from typical occupational therapy interventions, such as assistive devices (Johansson, Lilja,
Petersson, & Borell, 2007). Regardless of its psychometric properties, the FIM is useful only in specific
circumstances (e.g., screening and measuring the
141
outcomes of remediation interventions) and is potentially detrimental in demonstrating the efficacy of
adaptive interventions. When standardized tools are
not available or not appropriate, therapists should
use qualitative evaluation strategies, such as interviews and skilled observations that are trustworthy
and consistent (Law & Baum, 2005) and ensure that
information gathered using these invaluable strategies is adequately documented.
CONCLUSION
Evaluation serves a number of purposes.
Primarily, therapists use evaluation to identify and
examine misfits between the person, occupations,
and environment. However, it is also valuable in
screening referrals to identify people with potential
occupational performance issues and to measure
the magnitude of change in occupational performance resulting from home modification interventions. Professional reasoning is used throughout the
evaluation process. Drawing on relevant practice
frameworks and existing bodies of knowledge, therapists seek and interpret cues and generate and test
hypotheses about the person’s occupational performance difficulties and contributing factors. They use
narrative reasoning to understand and describe each
client’s unique experience of his or her situation and
to work with him or her to create an impelling future.
Pragmatic reasoning assists therapists to work sensibly and effectively within their personal resources,
as well as the resources available in the practice
context, and ethical reasoning requires therapists
to reflect on their personal and professional values
when dealing with the many competing forces that
affect thinking and decision making. Finally, interactive reasoning supports the development of a strong
therapeutic relationship between the therapist and
the client, enabling a collaborative alliance between
the two parties that enhances the potential for success of therapeutic interventions.
Therapists use a range of evaluation strategies to
gather information about the client, his or her occupational performance, and his or her home. Informal
interviewing is used to develop two-way communication between the therapist and the client, allowing
therapists to build collaborative partnerships; earn
clients’ trust and confidence; gather information;
hear stories; and understand clients’ experiences,
concerns, goals, and aspirations. Structured interviews provide therapists with a framework for collecting demographic information, medical history,
and self-reported ability to undertake ADLs, as well
as information on the age, design, and features of
142
Chapter 6
the house. Dedicated checklists prompt therapists
to identify potential hazards or barriers for older
people and people with specific impairments, health
conditions, or disabilities.
Skilled observation allows therapists to observe
occupational performance in the client’s natural environment and identify factors that are contributing to,
or interfering with, performance. General observations provide a basis for discussing the impact of
aging and/or their health condition, impairment, or
disability on life within the home, and analysis of
specific occupations (in particular, those identified
as problematic during the initial interview) allows
therapists to examine the value, independence, adequacy, and safety of performance. A growing number of standardized assessments are available to
therapists to ensure that the information collected is
comprehensive, trustworthy or valid, and consistent
or reliable. Using valid and reliable measures allows
therapists to determine the extent of the problem
and evaluate the effectiveness of interventions in
addressing the identified problem or concern.
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Development of a comprehensive assessment for delivery
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7
Measuring the Person and
the Home Environment
Elizabeth Ainsworth, MOccThy, Grad Cert Health Sci
and Desleigh de Jonge, MPhil (OccThy), Grad Cert Soc Sci
Having a health condition or impairment can be
disabling, limiting a person’s capacity to manage
everyday tasks in the home or community. A home
environment that is not designed for a person’s specific needs is more handicapping than one whose
design is well suited to the occupant.
This chapter describes the information that needs
to be obtained to facilitate goodness of fit of the
person with his or her home and discusses the
contribution to this of an understanding of anthropometrics, ergonomics, and biomechanics. The
chapter describes the characteristics of the home
environment, such as the size of spaces, gradients,
illuminance, force, and sound, that affect occupational performance and identifies tools for measuring these characteristics. The chapter concludes
with information about factors that may influence
measurement practice in the home.
CHAPTER OBJECTIVES
By the end of this chapter, the reader will be able
to:
Ô Describe measurement and the types needed
for home modification
Ô Explain the relevance and limitations of anthropometrics, ergonomics, and biomechanics
Ô Describe methods for measuring people, equipment, and the home environment
Ô Discuss various measures that relate to home
design
Ô Describe measuring tools and resources
Ô Describe factors influencing measuring practice
Ô Explain the consequences of not using reliable
measuring techniques
THE IMPORTANCE OF
MEASUREMENT
Increasingly, occupational therapists are recognizing the importance of measurement in detailing the
attributes of clients, their equipment, and caregivers
so that they can be incorporated into the redesign
of the home environment. The following discussion
provides a general overview of measurement and its
importance, the types of measurements required for
home modification practice, and the consequences
of not using sound measurement techniques.
During the home modification process, therapists
gather information about the person-occupationenvironment fit by taking systematic and accurate
measurements of that person’s physical characteristics and features in the home environment that
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Ainsworth, E., & de Jonge, D. An Occupational Therapist’s
Guide to Home Modification Practice, Second Edition (pp. 145-174).
© 2019 SLACK Incorporated.
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Chapter 7
affect occupational performance. Measurements are
taken of the person, the equipment he or she uses,
and the caregiver to determine the environmental characteristics required to support successful
completion of a range of occupations in and around
the home. The person’s height, weight, width, and
depth (and those of his or her equipment and caregiver) and the person’s visual and hearing capacity
are examined to determine the space, load capacity, clearance, size, and placement of features and
illumination requirements in the environment. For
example, when designing a shower area for a tall,
heavy client who uses a customized wheelchair, the
therapist takes measurements of the person in his
or her wheelchair and observes transfers and movement within the bathroom to determine the circulation spaces required and the load capacity, size, and
placement of the drop-down shower seat. A broad
range of activities may occur within the different
areas of the home, so it is important that therapists
talk with the resident to understand how each area
of the home is used and how various activities are
undertaken in each area.
Therapists also measure aspects of the environment and their impact on occupational performance
or the health, safety, independence, quality of life,
and participation of people within the home. The features that are commonly examined include lighting,
color, space, heights, widths, distances, gradients,
force, and sound (Bridge, 2005). For example, a person with age-related vision changes who is experiencing difficulty mobilizing at night and in transition
zones (i.e., between the outside and inside of the
home) may need lighting levels measured to determine the need for enhanced or consistent lighting.
Good measurement practice is critical to good
design. Measurement, rather than assumption or
guesswork, enables modifications to be tailored to
clients’ requirements. Occupational therapists can
use these measurements to inform clients and other
stakeholders about the functional implications of
the various aspects of the design and location of
features in the environment. Measurements can be
used as a foundation for discussing the limitations of
the current situation and how activities or the environment can be changed to support occupational
performance. These measurements are especially
useful for highlighting the extent to which clients’
requirements fall outside of the design and performance criteria in the existing access and design
standards.
Several problems can arise when clients and their
environment are inaccurately measured. Clients can
be unwilling to accept recommended changes if
they perceive that these have not been tailored to
suit their specific requirements. Inadequate measurement can also result in solutions being poorly
designed, which can cause delays, disruption, and
extra expense for the service or client as he or she
navigates problems and renegotiates alternative
options with the client. Further, interventions that
have not been adequately tailored to the individual’s
needs are likely to fail, resulting in an accident or
injury, poor health, premature or unnecessary institutionalization, increased reliance on others, and a
reduced quality of life.
Effective measurement is informed by an understanding of the relevance and application of anthropometrics, ergonomics, and biomechanics. Each
of these fields can contribute to an understanding of the person-environment-occupation fit.
Anthropometrics can assist in understanding the
dimensions of static postures and dynamic movement and how population data are used to inform
design. This field of study informs therapists about
the diversity of human body characteristics and the
importance of providing individualized measures
of people who fall outside of the typical population
design range. It has also established standardized
methods of measurement, which can be used by
therapists when gathering individualized measurement information. Ergonomics provides therapists
with an understanding of human task demands, the
usability of environments, and the person-environment interaction. Biomechanics enables occupational therapists to appreciate the structural basis
for human performance, strength or power capabilities of the human body, and forces generated by
the body as people undertake activities (Standards
Australia, 1994).
ANTHROPOMETRY AND
ANTHROPOMETRIC MEASUREMENT
Anthropometry is the study of the shape, size,
and proportion of the human body; the strength
and working capacity or abilities; and the variation
of these characteristics in populations (Ching, 1995;
Paquet & Feathers, 2004; Pheasant, 1996; Pheasant &
Haslegrave, 2006; Steinfeld, Lenker, & Paquet, 2002;
Steinfeld & Maisel, 2012; Steinfeld, Paquet, D’Souza,
Joseph, & Maisel, 2010). Anthropometric data arising
from the static and dynamic measurements of the
human body are collected on various populations
and are used to guide the design of products, spaces,
environments, and systems (Australian Safety and
Compensation Council, 2009; Baker, 2008; Connell &
Sanford, 1999; Cooper, 1998; Pheasant & Haslegrave,
Measuring the Person and the Home Environment
147
Figure 7-1. The normal distribution represented by the bell-shaped curve.
2006; Steinfeld & Maisel, 2012; Steinfeld et al., 2002,
2010).
Large anthropometric data sets, some of which
have been derived from people in the armed forces
in various countries, have been compiled and presented in multiple tables with detailed measures for
different subgroups (e.g., age and gender; Conway,
2008). When measures of individuals within populations are graphed, they commonly form a normal or
bell-shaped curve, with an increasing proportion
of the population tending toward the mean near
the middle of the curve and a decreasing proportion tending toward the tails of the curve (Diffrient,
Tilley, & Bardagjy, 1974), although not all anthropometric measures are symmetrically distributed. It
is important that designs sufficiently accommodate
anthropometric variability (Pheasant & Haslegrave,
2006). Customarily, measurements for 90% of the
population are used for designs; that is, the anthropometric dimensions occurring at either end of or
between the 5th and 95th percentiles (Goldsmith,
2000; Pheasant & Haslegrave, 2006; Steinfeld &
Maisel, 2012) or at or below the 90th percentile
(Figure 7-1). Critics have noted that designs based
on the 95th percentile for one dimension, such as
height, will not accommodate the 95th percentile
for other dimensions such as vision, hearing, and
perception (Sanford, 2012). This approach presumes
that there are no differences across populations
based on gender or other individual attributes that
would influence design and, as a result, it can be
assumed that no design will suit 90% of all people
across all abilities (Sanford, 2012). Some designs that
extend beyond the 95th percentile may only cater to
one type of ability, which can render the design even
more disabling (Sanford, 2012).
Published anthropometric data may be relevant
to some people within populations but not to others as the data have historically tended to exclude
people with a disability. Published anthropometric data might therefore provide little information
about the characteristics of people with a disability
(Steinfeld, 2004; Steinfeld & Maisel, 2012). A small
number of studies, undertaken in the late 1970s
and early 1980s, have provided limited data on the
anthropometrics of people with a disability. Many
studies on people with a disability are limited in
their usefulness because they have tended to focus
on specific disability groups rather than on the full
range of people with a disability, lack standardized
dimensional definitions and measurement methods
(Bridge, 2005; Paquet & Feathers, 2004), and do not
include or acknowledge the specific requirements
of people with more than one disability (Bridge,
2005). Further, the data do not consider the various
types of assistive devices used by a range of people
with a disability and how and when they are used
(Steinfeld, 2004).
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Chapter 7
Figure 7-2. Standing anthropometrics. (Adapted from
Goldsmith, S. [2000]. Universal design: A manual of practical guidance for architects. London: Elsevier.)
Despite the difficulties associated with applying
anthropometric data to people with a disability and
across subgroups of them, the available data can
assist therapists in understanding the complexities
of the human form and how it interfaces with the
environment (Baker, 2008). Anthropometric data are
necessary when the characteristics of individuals
are unknown or when establishing initial estimates
of measures of the characteristics where the individual is known. Whatever the case, therapists should
understand that, when designing for a particular
person, it is important that individualized measuring occurs. Without individualized measurements,
the suitability of the home modification for the client
might be compromised.
Types of Anthropometry and
Their Application
Two types of anthropometry are used to guide
design: structural (or static) anthropometry and
functional (or dynamic) anthropometry (Steinfeld &
Maisel, 2012).
Structural (Static) Anthropometry
This form of anthropometry “is the science of
measuring length, breadth, and the width of the
human population” (Baker, 2008, p. 75). It can
include the measurement of size of body parts,
stature, and weight (Steinfeld & Maisel, 2012). Static
measurements are usually taken with the person
sitting, standing, and/or bending (Steinfeld & Maisel,
2012). Human dimensions are always considered in
the sagittal plane (the vertical plane through the
longitudinal axis that divides the body into left and
right sections) or the coronal plane (the vertical
plane through the longitudinal axis that divides the
body into front and back sections; Baker, 2008).
The standing posture involves the subjects standing erect and looking straight ahead, with their
arms in a relaxed position by their side (Baker,
2008). The seated posture involves the subjects sitting erect and looking straight ahead. Their thighs
should be parallel to the floor and their knees bent
at a 90-degree angle with feet flat on the floor; the
upper arms are to be relaxed and perpendicular to
the horizontal plane with the forearm at right angles
to the upper arm and parallel to the floor (Baker,
2008). Measurements are taken along imaginary
horizontal or vertical lines using specific anatomical
landmarks, such as the popliteal crease at the back
of the knee, greater trochanter of the femur, and
parts of the body, as reference points. For example,
a person’s stature is determined by measuring the
vertical distance from the floor to the vertex (the
crown of the head). This measurement is then used
to define the vertical clearance required when standing, walking, or wheeling in an area of the minimum
acceptable space or with overhead obstructions.
The most common static body dimensions to obtain
in relation to the design of home interiors include
height, weight, sitting height, eye height, buttock
to knee and buttock to popliteal lengths, breadths
across elbows and hips, seated knee and popliteal heights, and thigh clearance height (Panero &
Zelnik, 1979; Figures 7-2 and 7-3).
Measurements to note in Figure 7-2:
Ô A = Floor to top of head
Ô B = Floor to shoulder
Ô C = Floor to elbow
Ô D = Waist to hand
Ô E = Floor to wrist
Ô F = Floor to eye level
Ô G = Diagonal reach range—floor to hand
Ô H = Diagonal reach range—floor to hand
Measurements to note in Figure 7-3:
Ô A = Floor to top of head
Ô B = Floor to top of shoulder
Ô C = Floor to popliteal area
Ô D = Chest to end of hand
Ô E = Floor to top of knee
Ô F = Floor to eye level
Ô G = Diagonal forward reach
Measuring the Person and the Home Environment
149
Anthropometric data on people with disabilities
also include dimensions of people occupying assistive devices. Dimensions of an occupied wheelchair
are used to determine the floor space and vertical
and horizontal clearance requirements of people
using wheelchairs.
Functional (Dynamic) Anthropometry
This form of anthropometry involves the measurement of a subject while in motion to help determine the properties of the body, such as range of
motion or reach, grasping, stride, clearance, and
space envelopes required for different body movements (Ching, 1995; Cooper, 1998; Steinfeld & Maisel,
2012). This can also include the measurement of the
subject during movement associated with certain
tasks, such as reaching, using an assistive device to
wheel or walk straight ahead or to make a turn, or
the measurement of the subject’s strength (Steinfeld
et al., 2002; Steinfeld & Maisel, 2012). These types
of data are more difficult to reliably obtain because
of the movement of the subject during the measurement process. However, functional or dynamic
anthropometry provides more accurate information
about the movement within spaces and during activities. For example, when considering the ability of the
body to reach forward, the static measurement that
would be used is “arm length” (Australian Safety and
Compensation Council, 2009). However, dynamic
analysis of a person reaching forward shows that
the shoulder joint also moves forward with the arm,
thus increasing the person’s forward reach capacity beyond the static length of the arm (Australian
Safety and Compensation Council, 2009, p. 42).
The size, shape, weight, and movement patterns
of people with disabilities vary considerably, requiring the environment to be customized to their
unique requirements. Occupational therapists use
the principles of anthropometric measurement to
position clients and locate anatomical landmarks
and parts of the body when establishing clients’
specific dimensions. Using an established and standardized approach to measurement, where possible,
ensures that practice is accurately and consistently
replicated by staff, particularly when there is a range
of approaches. Individualizing the measurement
process is particularly useful where usability and
safety require a close fit between individuals, their
equipment and caregivers, and their environment
(Steinfeld, Schroeder, Duncan, et al., 1979; Steinfeld
et al., 2002; Steinfeld & Maisel, 2012). For example,
a bathroom needs to be designed to “fit” an individual’s stature and functional reach range to ensure
his or her safety and the usability of the fittings.
Specifically measuring a person allows therapists to
Figure 7-3. Seated anthropometrics. (Adapted from Goldsmith,
S. [2000]. Universal design: A manual of practical guidance for
architects. London: Elsevier.)
collect concrete and scientific information that can
be used to analyze why a space is not working and
design or redesign spaces to suit the needs of users
with specific requirements (Goldsmith, 2000).
BIOMECHANICS
Biomechanics “is effort produced by the human
body while moving or resisting force” (Steinfeld &
Maisel, 2012, p. 103). It is the study of human movement using mechanical principles (Spaulding, 2008a).
It examines movement and equilibrium using the
principles of physics to investigate the influence of
forces, levers, and torque on performance (Pedretti,
1996). Because the biomechanics of the human body
are so complex, no single biomechanical model of
the human body currently exists; rather, there are
many models from various fields of use to explain
movement of the human body (Kroemer, 1987).
Biomechanics can be used to analyze movement
in everyday activities to understand the mechanical
aspects of the movement. It assists in the examination of the level of effort required to use the environment to accommodate end users’ abilities, tolerances, and preferences (Steinfeld & Maisel, 2012, p.
103). In a biomechanical analysis of the sit-to-stand
transfer, Laporte, Chan, and Sveistrup (1999) highlight the role of displacement, momentum, velocity,
and the relationship between the center of pressure
and center of mass throughout the four phases of the
sit-to-stand transfer. This type of analysis provides
therapists with a detailed understanding of the elements of the movement and how variations in movement may result in performance difficulties.
Using biomechanical principles, therapists systematically observe performance in order to examine
150
Chapter 7
the quality of the movement, the effectiveness of
performance, the degree of effort involved, and the
potential for injury (Kreighbaum & Barthels, 1996;
Pheasant, 1987; Steinfeld & Maisel, 2012). By using
a qualitative biomechanical analysis, therapists can
identify ineffective or problematic aspects of movement. Considerations commonly include:
Ô Range of movement: Working outside of safe
ranges of motion and/or within extreme ranges
Ô Center of gravity: Displacement of the person’s
center of gravity outside of the base of support
Ô Accuracy: Imprecise
movements
or
uncoordinated
Ô Speed and momentum: Slow, hesitant, uncontrolled, or impulsive actions
Ô Strength: Overexertion or ineffective positioning resulting in poor use of force, levers, and
torque
Ô Endurance: Limited activity tolerance or excessive energy expenditure (Steinfeld, Schroeder,
Duncan, et al., 1979)
Occupational therapists also draw on biomechanical principles to improve movement and make it
safer. They identify the most appropriate posture
for the performance of a task with a view to maximizing the effect of forces and minimizing muscular
effort (Pheasant, 1987). They also advise on strategies to improve the effectiveness and efficiency of
movement and reduce the likelihood of discomfort,
pain, incidents, accidents, injuries, or disability. For
example, occupational therapists use the information on the biomechanical analysis of the sit-to-stand
transfer provided by Chan, Laporte, and Sveistrup
(1999) to identify a range of strategies to improve
the effectiveness and safety of the movement (e.g.,
the ideal initial body position and the proper use of
body mechanics throughout the movement).
ERGONOMICS
Ergonomics is concerned with shaping environments and tasks to optimize the abilities of individuals to perform activities (Baker, 2008; Conway, 2008;
Stein, Soderback, Cutler, & Larson, 2006). It involves
measuring and using the dimensions of objects
and spaces to examine the human task demands
(Conway, 2008; Stein et al., 2006). Though ergonomics
emerged from the area of work performance, worker
safety, and productivity, it is not solely confined
to workplace environments (Berg Rice, 2008). The
concepts and principles are derived from research
in many fields, including industrial engineering,
human factors psychology, occupational medicine,
and nursing, as well as occupational therapy (Stein
et al., 2006). Like occupational therapy, the field of
ergonomics is concerned with the usability of environments and the person-environment transaction
(Conway, 2008). The principles of ergonomics can be
used to prevent musculoskeletal injures, conserve
energy, and use the body in the most efficient way
possible when engaging in activity or occupation
(Stein et al., 2006).
Two approaches are commonly used in an ergonomic evaluation: task analysis and user trial
(Pheasant & Haslegrave, 2006). Task analysis
involves examining what the person is doing or
needs to do and analyzing the physical movements
and information processing involved and the actual
or potential environmental barriers or constraints
(Conway, 2008). An effective task analysis involves
clarifying the person’s goals; intended outcome; and
potential areas of mismatch between the person,
activity, and environment (Conway, 2008). A user
trial involves the naturalistic trial of a product or
environment to determine its usability (Conway,
2008) and to evaluate whether there is a satisfactory
match with the user when considering its comfort,
usability, and performance (Pheasant, 1987).
With its user-centered approach and personenvironment transactive perspective (Pheasant &
Haslegrave, 2006), ergonomics can assist occupational therapists to determine the adequacy of the
person-environment fit (Conway, 2008; Stein et al.,
2006). Ergonomic principles guide the analysis of
the person’s posture, movement, and performance
and the impact of the environment (Berg Rice, 2008).
An ergonomic approach provides therapists with a
framework for evaluating and matching the design
of the layout, fittings, and fixtures to suit the specific capabilities of the person; additionally, it assists
in selecting products, equipment, and designs to
improve client or caregiver efficiency, effectiveness,
and safety (Berg Rice, 2008).
MEASURING THE CLIENT,
EQUIPMENT, AND CAREGIVERS
People vary in terms of their body size and movement patterns, the equipment they use, and the
assistance they receive; hence, therapists often need
to take an individualized approach when measuring clients, their caregivers, and their equipment.
Therapists gather this information to alert builders and designers to the specific requirements of
clients whose dimensions or abilities fall outside of
Measuring the Person and the Home Environment
the population addressed by the access and design
standards. Individualized measurement is advisable,
particularly for people who vary substantially in
terms of height, size, or weight and for those who use
equipment other than a standard wheelchair; have
impairments that affect their posture, movement,
or balance; have limited use of their upper limbs; or
require caregiver assistance for various activities.
The challenge for occupational therapists lies in
knowing what to measure and how to measure it.
By measuring people’s size, shape, weight, space
requirements (with consideration for their equipment and/or caregiver dimensions), reach, clearance, posture, and strength, the therapist can determine the space they require and the best location for
fixtures and fittings.
Individuals’ body dimensions might need to be
measured in various static or dynamic postures,
such as sitting, standing, bending, kneeling, squatting, or lying positions, depending on the nature of
the activities they are involved in around the home.
Posture relates to the orientation of body parts in
space and depends on the dimensions of the body
and their relationship with items in the environment. People with poor strength and endurance or
visual difficulties might experience change in posture throughout the day or alter their posture for
different activities. Posture might vary as a result of
natural biological fluctuations. For example, a person’s stature can vary approximately 15 mm over 24
hours, being the greatest first thing in the morning
when the spine has been relieved of supporting body
weight through lying down overnight (Pheasant
& Haslegrave, 2006). Shrinkage of the spine tends
to occur rapidly within the first 3 hours of rising
(Pheasant & Haslegrave, 2006). It may not always
be possible to measure clients in seated or standing
positions. In these cases, therapists need to choose
the posture that best suits the clients’ disability, the
activities they wish to complete, and the environment in which they will function in that position.
For example, if a client needs to reach to operate
an intercom while in bed, he or she will need to be
measured lying down and reaching to the area on
the wall that would best suit the person’s capacity
to operate the device.
The following diagrams and photos provide an
illustration of typical body postures and the location of the body landmarks used as reference points
during the measurement process. Pheasant and
Haslegrave (2006) provide a detailed description of
body dimensions and what these dimensions apply
to in relation to the design of the built environment.
The examples provided in the following discussion
are the measures most commonly taken by occupational therapists.
151
The Height, Width, and Depth of
Parts of the Body
The therapist uses a tape measure to determine
height, width, and depth of parts of the person
and the equipment above floor level. Pheasant and
Haslegrave (2006) provide the following details:
Ô A person’s stature is determined by measuring the vertical distance from the floor to the
vertex (the crown of the head). This measurement defines the vertical clearance required
when standing, walking, or wheeling in an area
or the minimum acceptable space of overhead
obstructions.
Ô Shoulder height is measured from the floor to
the acromion (the bony tip of the shoulder),
and it is the reference point for the location of
fittings, fixtures, and controls.
Ô Knee height includes the horizontal distance
from the floor to the upper surface of the knee
(measured to the quadriceps muscle and not
the knee cap), and it provides measurement
to inform the clearance required beneath the
underside of tables.
Ô Popliteal height is the measurement from the
floor to the popliteal angle at the underside
of the knee where the tendon insertion of the
biceps femoris muscle is located. This dimension defines the maximum acceptable height of
the seat.
Ô Hip width is the maximum horizontal distance
across the hips in the seated position, and this
information relates to the minimum width of a
seat.
Ô Hand width is measured across the palm of the
hand and includes a measurement of the distal
ends of the carpal bones to provide information on clearance for hand access to handles
or rails.
Ô Depth of the area between the popliteal area at
the underside of the knee to the rear of the buttocks provides information to inform the design
of the depth of a seat (Figures 7-4 and 7-5).
Measurements to note in Figure 7-4:
Ô A = Shoulder width
Ô B = Seat to the top of the shoulders
Ô C = Seat to the top of the head
Ô D = Width of the buttocks
Ô E = Width of the seat
Ô F = Bottom of buttocks to the elbow
Ô G = Seat to the lumbar area
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Chapter 7
Figure 7-4. Rear and side views of a seated person. (Adapted
from Pheasant, S. [1996]. Bodyspace: Anthropometry, ergonomics
and the design of work. London: T. J. Press.)
Figure 7-5. Occupied wheelchair. (Adapted from Goldsmith, S.
[2000]. Universal design: A manual of practical guidance for architects. London: Elsevier.)
Ô C = End of armrest to end of toe
Ô D = Floor to toe with foot on footplate
Ô E = Floor to seat of wheelchair (or top of cushion on wheelchair)
Ô F = Floor to knee with foot on footplate
Ô G = Floor to eye level
Ô H = Diagonal forward reach
Ô I = Height of wheelchair
Eye Height
The therapist also measures eye height, which
is measured from the floor to the inner canthus
(corner) of the eye. This dimension defines the maximum acceptable height for visual obstructions and
defines sight lines (Pheasant & Haslegrave, 2006; see
Figures 7-2 through 7-6).
Reach Ranges
Figure 7-6. Measuring eye height above floor level.
Ô H = Rear of the buttocks to the popliteal area
of the leg
Ô I = Floor to the popliteal area
Measurements to note in Figure 7-5:
Ô A = Chest to toe
Ô B = Edge of armrest to end of toe or footplate
(whichever protrudes the most)
The measurement of an individual’s functional
reach ranges, when positioned in various postures,
is important in determining the width and height of
environmental features, such as storage cupboards,
benches, and clotheslines. The therapist considers
the location of the features in the environment and
asks clients to move and reach either forward or
sideways with the arm they are most likely to use.
This activity could also be undertaken in a natural
environment in which the various features are positioned, or the therapist might need to simulate the
location of the various features during the measurement exercise. Refer to Figures 7-2 through 7-12.
Measurements to note in Figure 7-7:
Ô A to G = Side reach
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153
Figure 7-7. Occupied wheelchair. Side reach. (Adapted from
Goldsmith, S. [2000]. Universal design: A manual of practical guidance for architects. London: Elsevier.)
Figure 7-8. Measuring horizontal reach dimension.
Figure 7-9. Measuring forward horizontal functional reach
above floor level.
Figure 7-10. Measuring forward diagonal functional reach
above floor level.
Determining the Size of Spaces for Transfer
and Mobility Equipment
Reflecting the distinction between static or
dynamic studies in anthropometrics, two strategies for determining the size of spaces for occupied or unoccupied mobility equipment such as
wheelchairs, scooters, or wheeled walking aids can
be differentiated, depending upon whether the person is stationary or moving. The distinction is made
here because sizes of spaces for stationary equipment can be determined from measurements of the
occupied or unoccupied equipment itself, whereas,
in practical terms, determining the sizes of spaces
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Chapter 7
Figure 7-11. Measuring side horizontal functional reach above
floor level.
for moving equipment cannot. Spaces to consider
when measuring equipment in motion include volumetric (three-dimensional) space and planar (twodimensional) space traversed on the travel surface
(i.e., the ground or floor surface).
Most rooms and spaces in the home will require
consideration of the motion of equipment; however,
consideration of stationary equipment is necessary
for storage and parking spaces and at the start and
end positions of their motion.
Measurements for Stationary
Mobility Equipment
For the minimum size of spaces to store or park
equipment, measurements will be required of at
least the overall width, length, and height of the
equipment. For more compact storage, such as
under bench tops for wheelchairs, the dimensions
of foot, back, and arm support assemblies and drive
wheels will also be required. For even more compact
storage of equipment that can be folded, measurements will be required of them in their folded state.
Occupied and unoccupied wheelchairs and scooters are typically illustrated in plain view as being
symmetrical about their longitudinal and lateral
axes. However, many unoccupied and especially
occupied pieces of equipment are asymmetrical
(Hunter, 2009). Asymmetry is attributable to the
equipment, the occupant, accessories such as respirators, and loose items such as handbags and
walking aids. The need for consideration of loose
items in space planning should be confirmed with
clients. Figure 7-13 illustrates the typical asymmetry
of wheelchairs and scooters.
Figure 7-12. Measuring side diagonal functional reach above
floor level.
Measuring unoccupied or occupied wheelchairs
and scooters requires measurement of the distance
between outermost points on them. These are typically on hand rims, the rear of drive wheels, the ends
of handgrips, the tops of back supports, and the
ends of armrests and footplates. Outermost points
on users of manual or powered wheelchairs include
the ends of shoes and elbows, fingers, or wrists on
hand rims or controls and the top of users’ heads.
Outermost points may also be on features or accessories added to the equipment by clients. Outermost
points on users do not necessarily occur at the
skeletal protuberances commonly used as reference
points in biomechanics.
Prior knowledge of key features that typically
constitute the two- and three-dimensional outlines
of occupied and unoccupied equipment assists in
orienting to the measuring task. Of greatest importance, however, is skill in recognizing the features
that constitute the envelope of occupied or unoccupied equipment and the relevant outermost points
on it.
The number of points is determined by the end
use of the measuring. If the end use is to determine
the size of a cube for storing equipment, only the
Measuring the Person and the Home Environment
155
Figure 7-13. Typical outlines of occupied wheelchairs and scooters. (Reprinted with permission from Rodney A. Hunter.)
pairs of points corresponding with overall width,
length, and height of the equipment are required. For
space under bench tops and the like for wheelchairs,
dimensions of arm support assemblies, legs, and feet
positions will also be required.
Methods for recording outermost points include
photogrammetry and laser scanning; however, these
can be time consuming and costly. Simple, inexpensive, and sufficiently accurate methods for most
home modifications are manual ones. The most
common and quickest manual method is measuring
between outermost points of the equipment with a
tape measure.
If only the overall length and width need to be
measured, movable panels can be used. Polystyrene
is a suitable material for panels; the panels need to
have a base that is large and heavy enough to stabilize the panel. For this method, the panels are placed
parallel to each other and at each side of the equipment and then moved toward it until they just touch
it. The procedure is repeated at the ends of the equipment. There are three advantages of this method:
1. The panels can be easily placed at whatever
angle with respect to each other and that most
snugly contains the equipment for purpose of
storage space that is not rectangular in plan
2. The panels can be used to test for the parking
or storing motion of the equipment
3. No prior knowledge of measuring points is
required
For mobility equipment with castor wheels, a
dimension that may need to be measured is the
pivoting radius of the castor wheels. Castor wheels
can swing outside of the envelope of equipment,
especially if, after the equipment has stopped, it is
suddenly moved in the opposite direction. If there
is insufficient space for this, the equipment can
become jammed in the storage space.
The measured width and length of the stationary
equipment will need to be increased to allow for typical imperfect control of the equipment as it is driven
or pushed into or out of the parking or storage space.
Additional measurement will also be necessary
where space is required to transfer in and out of the
equipment or if space is required for another person
to assist the equipment user (Figures 7-14 through
7-22).
Measurements to note in Figure 7-14:
Ô L = Length of wheelchair
Ô W = Width of wheelchair
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Chapter 7
Figure 7-14. Unoccupied wheelchair.
Figure 7-15. Unoccupied wheelchair.
Figure 7-17. Occupied wheelchair. (Adapted from Goldsmith, S.
[2000]. Universal design: A manual of practical guidance for architects. London: Elsevier.)
Figure 7-16. Unoccupied wheelchair.
Measurements to note in Figure 7-15:
Ô L = Length of wheelchair
Ô H = Height of wheelchair
Measurements to note in Figure 7-16:
Ô W = Width of wheelchair
Ô H = Height of wheelchair
Measurements to note in Figure 7-17:
Ô L = Length from back of rear wheel to the
front of the footplate or person’s toe (edge that
protrudes)
Measurements to note in Figure 7-18:
Ô W1 = Width of the wheelchair without the
person’s hands on the wheel rims; width from
wheel rim to wheel rim
Ô W2 = Width of the wheelchair; person’s hands on
the wheel rims; width measurement to include
widest point (knuckles or elbows protruding)
It must be noted that some people with a disability have different body shapes, reach, and movement patterns that do not correlate with these
diagrams. In such cases, an individualized measurement approach is required.
Ô W1 = Width of the wheelchair without the
person’s hands on the wheel rims; width from
wheel rim to wheel rim
Measurement for Mobility
Equipment in Use
Ô W2 = Width of the wheelchair; person’s hands on
the wheel rims; width measurement to include
widest point (knuckles or elbows protruding)
Mobility equipment moves between stationary
states corresponding with parked or stored positions; the path between these positions is straight,
Measuring the Person and the Home Environment
157
Figure 7-19. Measuring the occupied wheelchair width.
Figure 7-18. Occupied wheelchair. (Adapted from Goldsmith, S.
[2000]. Universal design: A manual of practical guidance for architects. London: Elsevier.)
Figure 7-20. Measuring the occupied wheelchair length.
curved, or partly both. Parked positions that typically need to be considered in relation to equipment
motion include those in showers and at toilet pans,
hand basins, and kitchen sinks.
Measuring for Straight Paths or Curved Paths
of Large Diameter
For the cross-sectional dimensions of straight
paths or curved paths of large diameter, such as
height and width of paths, the minimum required
dimensions and the techniques for obtaining them
may be the same as those for stationary occupied
equipment. Curved paths of large diameter can be
treated similarly to straight paths because the relevant outermost points on the occupied equipment
will tend to be the same in each case.
Therapists should be aware that even if path
widths can be determined from the dimensions
of stationary equipment, widths will need to be
increased for typical imperfect control of equipment
and hence avoidance of damage and injury. The additional width will need to be estimated or measured
by trial and error using techniques discussed later.
Additionally, for long footpaths and corridors (and
for lifts), space might be required for a 180-degree
turn, for which the required space will need to be
established as discussed later.
Measuring for Maneuvering and Curved Paths
of Small Diameter
The term maneuvering here denotes motion composed of turns with a very small diameter, including
reversing turns that involve alternating forward and
backward motion.
Determining the size of spaces from measurements of stationary equipment is much more difficult for maneuvering and for curved paths of small
diameter than it is for straight travel or curved paths
of large diameter. This is because the relevant outermost points tend to be different between the two
cases and different for different maneuvers. This is
illustrated in Appendix B. The detail in the appendix
illustrates that, for four types of 90-degree clockwise
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Chapter 7
Figure 7-21. Measuring the height of the toe above floor level.
Figure 7-22. Measuring knee height above floor level.
turns, three different pairs of outermost points
determine the width of the space.
Because of the complexity of estimating or calculating space for equipment in motion by using
measurements of the occupied equipment when they
are stationary, it may be much better to measure the
spaces occupied by the moving equipment.
Two methods for determining the size of space
for maneuvering are recording the space traversed
on the floor by the moving equipment and then
measuring that space, and using barriers as measuring datums between which to measure dimensions
of the space. In this latter method, the barriers act
as a large measuring tool with adjustable reference
planes (datums).
The first method does not require barriers; however, barriers add greater realism and possibly
greater accuracy to path recording. For the second
method, the barriers are incrementally positioned
closer to or farther away from the occupied equipment until the client reports or it is observed that
the maneuver occurs in the least space with reasonable ease and without touching the barriers.
The space traversed by moving equipment can
be recorded using a physical scale model fitted with
pens (Hunter, 2003a); actual occupied equipment
fitted with pens (Ringaert, Rapson, Qiu, Cooper, &
Shwedyk, 2001); sonar or video recording devices;
pressure-sensitive mats that record electronically or
physically (Hunter, 2003b); or computer simulation
(Han, Law, Latombe, & Kunz, 2002; Hunter, 2005).
For home modifications, these techniques may be
too costly and time consuming. Furthermore, physical scale modeling and computer simulation require
additional information for estimates about spatial
allowances for steering control and navigational
judgments by equipment users and about the space
occupied by people assisting the user (this additional information would need to be obtained by one of
the other methods using actual equipment).
Barriers as a Measuring Tool
The use of incrementally adjustable barriers as
a measuring tool is a simple method suitable for
home modifications. The barriers may be simplified
ones (Hunter, 2002), replicated or actual barriers
(Steinfeld, Schroeder, & Bishop, 1979), or simple
panels as previously noted. An advantage of this
method is that knowledge of the dimensions of the
occupied or unoccupied equipment or of equipment
users’ steering control or navigational judgments
is not required, although the latter may need to be
Measuring the Person and the Home Environment
159
Figure 7-23. Imperfect turn around bollard. (Reprinted with permission from Rodney A. Hunter.)
specified as part of the testing. The method can
also readily incorporate the contribution to space
requirements of people assisting the equipment
user. Measuring may be easier in premises other
than the home but may incur logistical difficulties.
Measuring may be more feasible in homes if
chalked or taped lines on the floor are used instead
of moveable panels. If the maneuvering overlaps
lines, they can be replaced or augmented by lines
alongside them. Care is required to identify whether
any part of the occupied wheelchair overlaps the
lines.
Understanding an Individual’s Space Needs
A measuring project for a home is facilitated by
first learning how clients move about in their homes,
in particular, how areas are approached, activities
in them carried out, and the areas departed. For
example, when examining the space requirements
of a wheelchair user during toileting, observations
need to be made of the client’s capacity to wheel to
the room, negotiate the doorway, wheel beside or
in front of the toilet, transfer on and off the toilet,
access and use the hand basin, and then depart from
the area. Movement must be possible without having
to move furniture or inflicting damage to walls and
doorways and other fittings and fixtures.
Consideration may also need to be given to the
circumstance where more than one wheelchair is
used in the home and whether a wheelchair may be
changed in size or type after a period. The equipment that requires the greatest space will therefore
probably have to take priority over the others in
determining space requirements.
The Geometry of Curvilinear Travel
Understanding the basic geometry (shapes) of curvilinear travel can be useful for measurement projects. The geometry of curvilinear travel is infinitely
variable, but some generalizations are possible.
In terms of geometry of travel, common types of
wheelchairs and scooters are rear-, mid-, and frontwheel-drive wheelchairs and three- and four-wheel
scooters. The geometry of scooter travel is similar
to tricycles. The type, size, and shape of wheelchairs
determines the least possible space required for
them; that is, the space required by them as if they
were perfectly driven. There can be a pronounced
variation between the spaces traversed by different
wheelchairs in terms of sizes and shapes and the
location of the spaces in relation to the physical feature with which the turn is associated.
Curvilinear travel and maneuvers are typically
composed of circular turns and noncircular turns
such as hyperbolic-shaped turns (the diameter of
the turn path becomes successively bigger or smaller throughout the turn). Each of these turn types
may be performed as a single motion in the one
direction (clockwise or counterclockwise) or as
several motions in different directions as occurs
in reversing turns. Most maneuvers involve reversing turns of varying complexity. A predominantly
single-motion turn can also incorporate a very small
reversing turn (Figure 7-23 shows an imperfect turn
around a bollard).
Motion at a feature can be regarded as a single
maneuver, with start and end stationary positions
(even though the equipment may be stationary for
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Chapter 7
a barely measurable period). Approach and departure travel paths also need to be considered to
this maneuver because of their contribution to the
overall size of space required at the feature and,
importantly, because of their influence on the type
and therefore size and shape of the space traversed
by the maneuvering.
Of relevance to the conventional incorporation of
right-angled room layouts in buildings is categorization of compact turns of wheelchairs and scooters
in terms of a small number of fundamental types.
These are 360-, 180-, and 90-degree turns about the
midpoint between the drive wheels of wheelchairs;
90-degree turns about either of the drive wheels of
wheelchairs; 360-, 180-, and 90-degree turns about
the center of the smallest turning circle of scooters (or tricycles); and noncircular turns. Reversing
turns can be categorized as 180-degree turns, of
which two types can also be differentiated, although
reversing turns are really just successive 90-degree
turns. Examples of these fundamental types of turns
are indicated and further explained in Appendix B.
In reality, the variety of turns employed by wheelchair and scooter users, knowingly or otherwise, is
infinite. Nevertheless, knowledge of the fundamental
types of turns allows an approximation or initial estimation of maneuvering space requirements.
Turns of 360 degrees are applicable to general
living areas or other spaces in which there is no predominant direction of travel. Spaces for 180-degree
turns are smaller than spaces for 360-degree turns
and may be acceptable to clients. Turns of 90
degrees apply to doorways and corners of corridors
or footpaths.
The fundamental turns should not be regarded
as absolute bases for determining sizes and shapes
of spaces for equipment use. Rather, they should be
used as initial approximations in designing, or for
the initial setup of panels or floor lines for maneuvering trials. Whether the size of spaces should be
determined with reference to any one of the fundamental turns will be a matter of trial and error and
collaboration with the client.
Procedures for Measuring
Maneuvering Spaces
360-Degree Turn Test
The occupied equipment is positioned in a corner
formed by fixed panels or the walls of a room; two
relocatable panels or other barriers or floor lines are
placed parallel and opposite these walls to enclose
the occupied equipment. Starting from a position
facing one of the fixed elements, the person operating the equipment then performs a 360-degree turn.
If space is insufficient or excessive, the moveable
elements are gradually and successively positioned
until the turn can be performed without the equipment or the person’s body touching the walls or
overlapping the barriers (International Organization
for Standardization, 2005) as per Figure 7-24.
180-Degree Turn Test
A fixed panel or wall of a room is used as one side
of a corridor, and a moveable panel or other barrier
or line marking is placed parallel with it as the other
side. Starting from a position between the panels
and facing along the corridor, the person operating
the equipment performs a 180-degree turn. If space
is insufficient or excessive, the moveable element is
gradually and successively positioned until the turn
can be successfully performed.
Two trial procedures should be conducted: one
where the 180-degree turn is performed as a single
turn in a clockwise or counterclockwise direction or
both, and the other as a reversing turn as illustrated
in Appendix B. Two reversing turn trials should also
be undertaken: one where the initial motion is forward and one where the initial motion is backward
as shown in Diagrams 9 and 10 in Appendix C.
90-Degree Turn Test
Two types of 90-degree turns should be tested:
around the corner of a corridor (or through a doorway into a corridor) or from a corridor through a
doorway. Instead of or as well as the corridor corner
test, turns around the outside and inside of wall corners (that is, not in a corridor) will yield additional
information. The procedures are similar to those for
360- and 180-degree turns. For the outside and inside
corner tests, the wheelchair users should be asked
to stay as close to the corner as possible. There are a
large number of other configurations and maneuvers
that might also need to be tested.
Specifying Circular or Noncircular Turns
Though it is easy to distinguish between circular
and noncircular turns on a drawing for 180-degree
reversing turns and 90-degree turns, actually testing
separately for these turns will probably be impracticable. What is important is that clients employ whatever strategy is most effective for them in performing turns in as little space as comfortably possible.
Weight
The weight of the person and his or her equipment can be measured using specifically designed
Measuring the Person and the Home Environment
A
B
C
D
Figure 7-24. Commencing a 360-degree turn.
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weight scales. Alternatively, the client might be able
to report his or her own weight at the time of the
home visit, and the weight of the equipment may be
documented in the technical specifications available
from medical equipment suppliers. This information
is important in designing ramps and other structures that need to take the load of the person and his
or her equipment, and these weights can be particularly important if the client has bariatric equipment
requirements.
Recording Measurement
Information
The measurement information can be recorded in
a form similar to Table 7-1, which has been compiled
from figures and information from Goldsmith (1976,
2000); Pheasant and Haslegrave (2006); Steinfeld,
Maisel, and Feathers (2005); and Steinfeld et al.
(2010).
Measuring Features in the Built Environment
The aspects measured in the environment depend
on the nature of the environmental barrier or issue
that is presented at the time of the home visit.
Therapists measure the observable aspects of the
home environment to gather information to assist
in the redesign of the area. Environmental features
typically measured include the length and width of
rooms and the height and location of fixtures and fittings. Distances and gradients can also be measured
when the person’s ability to mobilize around the
property needs to be addressed. In addition, therapists may wish to establish noise and lighting levels
throughout the home and the force required to open
and close doors and drawers.
At times, it might be necessary for a technical
specialist to visit the home to undertake more formal
and specific measurement activities, particularly in
cases where major modifications are to be undertaken or the therapist does not have the skill, training, and technical expertise in specific measurement
techniques. For example, a builder can be engaged
to measure the levels of external areas around the
home in order to design a ramp, or an acoustic engineer might be required to measure the sound levels
of a household.
The following section provides information on
the various tools and resources used to measure
features in the built environment.
Dimensions
Dimensions include measures of length, width,
and height and are taken using key reference points
within the built environment. These reference points
are conventions documented in publications such as
access standards for consistency and to establish the
start and finish of a measure. For example, the reference point for measuring dimensions of walls is the
finished face of the wall (i.e., the plaster sheeting or
tiling, which can be placed on the face of the plaster
sheet). The reference points for doorways are in the
inside face of the door jamb on the latch side of the
doorway and the face of the door leaf in the 90-degree
open position. The top of the hand rail or grab bar is
the reference point for measuring their height above
the nosing of the stair or floor. The center of the operable part of the power or light switch is the reference
point for measuring the height above the bench or
floor. The center line of the toilet is the reference
point for measuring the distance of the toilet from the
side wall. Figures 7-25 through 7-28 provide examples
of reference points in the built environment that are
used during the measurement process.
A number of resources are available to guide
therapists in measuring specific features in the
built environment and identifying specific reference points. Illustrations of the location of reference
points and corresponding dimension lines can guide
measurement practice, and they can be found in
resources such as the Comprehensive Assessment
and Solution Process for Aging Residents (Extended
Home Living Service, n.d.), which provides detailed
illustrations of the essential measurements for a
range of architectural features important to home
modifications, such as stairs at entrances and within
the home (Figures 7-29 through 7-32).
A range of tools are used to measure dimension
as illustrated in Figure 7-33. The most commonly
used tools to measure dimensions are the tape measure, distance meter (Figure 7-34), and stud finder
(Figure 7-35).
A tape measure should:
Ô Be at least 16-ft (5,000-mm) long to measure
features in the residential environment, such
as the length and width of the room and the
height of the ceiling
Ô Be made of metal rather than plastic or woven
plastic to ensure that this does not stretch,
twist, buckle, or sag and result in inaccurate
measurements
Ô Have markings that can be clearly understood
and recognized (Bridge, 1996)
Ô Have a wide tape blade so it can be aligned to a
feature in the home without sagging
When measuring:
Ô A tape measure is easier used on flat surfaces
and in an environment that is well lit.
Measuring the Person and the Home Environment
163
Table 7-1. Measuring a Person and His or Her Mobility Equipment
FEATURE
MEASUREMENT HOUSING FEATURES
(EXAMPLES)
BUILT ENVIRONMENT
DIMENSION REQUIRED
General Measurements of the Person—Seated or Standing
Height
Clearance below overhead obstructions
Width
Width of doors, hallways
Depth
Depth of shower seat
Height above floor level
standing—Head height
Height of window awnings
Height above floor level
seated—Head height
Height of window sills, mirror above
the vanity
Height above floor level
standing—Shoulder height
Height of fittings, fixtures
Height above floor level
seated—Shoulder height
Height of fittings, fixtures
Height above floor level
seated—Knee height
Height to the underside of sink
Popliteal height—Seated
Height of toilet, shower seat
Hip width
Width of shower seat
Hand width
Diameter of rails
Popliteal crease to back of
buttocks
Depth of shower seat
Height above floor level
standing—Eye height
Height of window sills, mirror above
the vanity
Height above floor level
seated—Eye height
Height of window sills, mirror above
the vanity
Functional Reach Range Measurements of the Person—Seated or Standing
Distance between chest
and edge of fingertips—
Horizontal reach
Width of counters
Height above floor level—
Forward horizontal reach
Height of power point above bench,
door handles, light switches, shelving,
towel rails
Height above floor level—
Side horizontal reach
Height of power point above bench,
height of shelving, width of laundry
hub, height of door handles, height of
window latches
Height above floor level—
Forward diagonal (up) reach
Height of hanging rail, clothesline,
power points, or cupboards, etc., with
straight-on approach
Height above floor level—
Forward diagonal (down)
reach
Height of power points or cupboards,
etc., with side-on approach
Height above floor level—
Side diagonal (up) reach
Height of hanging rail, clothesline,
power points, or cupboards, etc., with
straight-on approach
Height above floor level—
Side diagonal (down) reach
Height of power points or cupboards,
etc., with side-on approach
(continued)
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Chapter 7
Table 7-1. Measuring a Person and His or Her Mobility Equipment (continued)
FEATURE
MEASUREMENT HOUSING FEATURES
(EXAMPLES)
Unoccupied and Occupied Equipment Measurements
Unoccupied Device
Width of device (unfolded)
Space for storing device
Width of device (folded)
Space for storing device
Length of device
Space for storing device
Height of device
Space for storing device
Occupied Device
Width of device (unfolded)
Circulation space required at doorways
off corridors, corridor width, ramp width,
path width, area required between kitchen
counters and in front of appliances
Length of device (unfolded)
Circulation space required at doorways off
corridors and on ramps that turn 90 to 180
degrees; area required between kitchen
counters and in front of appliances
Height above floor level—
Floor to toe with foot on
wheelchair or shower
chair footplate
Height and depth of toe recesses on
cupboards
Height above floor level—
Floor to knee or thigh
(highest point) with foot
on wheelchair or shower
chair footplate
Under sink clearance (bathroom and kitchen)
or under breakfast bar clearance
Height above floor level—
Wheelchair or shower
chair seat height
To compare to toilet seat height (for side- or
front-on transfers)
Height above floor level—
Floor to wheelchair or
shower chair armrest
Under counter clearance
Height above floor level—
Floor to hand on wheelchair control on armrest
Under counter clearance
Height of hoist legs
Under bath clearance
Width of hoist legs with
legs closed
Under bath clearance
Turning circles:
Circulation space required at doorways off
corridors and on landings on ramps that turn
90 or 180 degrees; area required between
kitchen counters, within a bathroom and
bedroom, in front of appliances and
cupboards, and at mailbox, clothesline, and
garden shed areas
90-degree turn
180-degree turn
360-degree turn
Weight
Weight of person
Weight load for lift capacity
Weight of device
Structural weight load for ramps
Other
BUILT ENVIRONMENT
DIMENSION REQUIRED
Measuring the Person and the Home Environment
165
Figure 7-25. Measuring the center line of the toilet.
Figure 7-26. Measuring the clearance of the doorway.
Figure 7-27. Measuring the datum point of the toilet.
Ô The area should be measured at least two or
three times to ensure the information is accurate and to establish the average measurement.
Ô Wall lengths should be measured at floor level
and at 35.5 in/900 mm above floor level because
walls are not always straight (Bridge, 1996).
A battery-powered distance meter can be used to
measure horizontal or vertical distances in rooms.
The distance meter is particularly useful when
measuring distances greater than 197 in/5 m (e.g.,
example, a vertical clearance such as floor to ceiling
or between two walls in a large room). Many distance
meters incorporate a laser pointer to assist in accurately positioning the beam for measurement.
Figure 7-28. Measuring the datum point of the vanity basin.
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Chapter 7
Figure 7-30. Measuring the clearance of a doorway with a sliding door. The measurement on top of the line is in inches (imperial measurement), and the measurement below the line is in
millimeters (metric measurement).
Figure 7-29. Measuring the clearance of a doorway with a swing
door. The measurement on top of the line is in inches (imperial
measurement), and the measurement below the line is in millimeters (metric measurement).
Figure 7-32. Measuring the height of a handrail above the nosing of a step. The measurement on the top of the line is in inches
(imperial measurement), and the measurement below the line is
in millimeters (metric measurement).
Figure 7-31. Measuring the height of a handrail above the
surface of a ramp. The measurement on the top of the line is in
inches (imperial measurement), and the measurement below
the line is in millimeters (metric measurement).
Figure 7-34. Using a distance meter to measure the length of
a room.
Figure 7-33. Tools to measure dimension.
Measuring the Person and the Home Environment
167
Figure 7-36. Diagram showing studs on a wall.
Figure 7-35. Tool used to locate studs.
When using a distance meter, ensure:
Ô The tool sits squarely on a wall or floor surface.
Ô The beam is aimed at a solid feature, such as
a wall or ceiling, and no plants, windows, wall
furnishings, lights, or other floating matter
interfere with the line of sight.
Ô Three sets of measurements are taken and an
average established to ensure the accuracy of
the data (Bridge, 1996).
Locating Structural Framing
The safe use of load-bearing aids in the home
such as grab bars and hoists typically requires that
they be fixed to wall or ceiling structural members,
such as wall studs or ceiling joists. Wall studs are
vertical structural framing members that occur at
intervals of typically 18 in (450 mm) or 24 in (600
mm) and to which the wall lining or sheeting is fixed
(Figure 7-36). Where such members do not occur or
are structurally inadequate for the aid, a new structural member will need to be installed within the
framing or on the face of the wall or ceiling lining but
fixed to the underlying structure.
Therapists may wish to determine the feasibility
of soundly fixing load-bearing aids in the preferred
locations for the client and therefore to identify the
location of framing members. Though this can assist
in designing the recommendation, it is preferable
that the tradesperson undertake an accurate assessment of the position and integrity of the structural
supports behind the wall facings. For this reason,
therapists might locate the position of studs but not
include this information in their drawings so that
the builder retains responsibility for determining the
capacity of the wall structure to support the grab
bar in the recommended location.
Framing members can be found by:
Ô Looking for joints in wall or ceiling linings that
indicates the direction of the framing members
(they will typically run at right angles to the
joints)
Ô Looking for lines of nails or screws
Ô Tapping along wall or ceiling linings to hear
changes from hollow to solid knocking sounds
(this may be ineffective for dense linings)
Ô A magnetic or electronic stud finder (for timber
studs)
Ô A magnet (for steel studs)
Greater accuracy can be achieved by using two
or more of these methods. A knowledge of the era
in which the home building occurred and the typical spacing and thickness of framing members will
expedite finding the framing members.
Electronic stud finders may be much more useful than magnetic ones. There are several different
types of electronic stud finders, including ones that
can be used for timber or metal framing and that
identify the presence of electrical wiring and metal
piping.
Tapping and stud finders should be employed
along a line at right angles to the direction of the
framing member. This will also confirm responses
of the stud finder to electrical wiring and metal
piping. For example, to find a wall stud, the stud
finder should be moved horizontally until a stud is
found. The method should continue past the stud
or else be repeated in the opposite direction so that
the thickness and hence midline of the stud can be
168
Chapter 7
Figure 7-37. Tools to measure gradient.
Figure 7-38. Measuring the gradient of the shower floor.
capacity of wall and ceiling structures for the fixing
of grab bars, hoists, and other aids.
Gradient
Figure 7-39. Measuring the verticality of the wall.
established. The procedure should be repeated at
two or more heights above the floor because the
wall studs will not be perfectly parallel with each
other or at right angles to floor and to avoid false
readings from noggings between studs and electrical
wiring or metal piping. Noggings are short horizontal
members located between and at approximately the
midheight of studs; they impart greater rigidity to
framed walls.
For ceilings, care is required to ensure that ceiling battens are not detected instead of ceiling joists.
Ceiling joists are small-sectioned members that are
fixed to the underside of ceiling joists to achieve,
among other things, greater planarity of the ceiling
lining (the ceiling lining is fixed to the ceiling battens,
not the joists).
Therapists should bear in mind that noggings and
ceiling battens are unlikely to be adequate for fixing
load-bearing aids. It would be prudent for therapists
to seek confirmation from design or construction
professionals about the suitability and load-bearing
The gradient, or slope, of surfaces influences the
ability of a person to walk or wheel around the home
and whether water will accumulate on the surfaces.
Obtaining measurements of gradients of ramps,
paths, landings, or shower floors enables comparison with design guides and standards and thereby
the determination of the suitability of the inclined
surfaces for ease and safety of movement and the
stationary positioning of equipment.
Two methods for determining gradients can be differentiated by trigonometric calculation and by use
of a gradient measuring device (Figures 7-37 through
7-39). To determine gradients by trigonometric calculations, at least two dimensions are required: the
horizontal and vertical dimension or either of the
horizontal or vertical dimensions plus the inclined
length. Part of the horizontal or inclined length and
the corresponding vertical dimension can be used
to calculate the gradient, but this will tend to be less
accurate than using the whole length of the inclined
surface. Similarly, for greater accuracy, using the vertical dimension with either the horizontal or inclined
length is preferable for calculations than use of the
horizontal and inclined lengths.
A gradient measuring device indicates the angular
difference of a surface with respect to the vertical.
Using a gradient measuring device is generally quicker and may be more convenient to determine gradients than by trigonometric calculation. Measuring
devices are available in various forms and are called
by a variety of names, including clinometers, slope
gauges, and gradient meters. Two commonly available devices are the clocklike device whereby the
gradient is indicated by a pointer with respect to
Measuring the Person and the Home Environment
169
Table 7-2. Conversion of Angle Data to Gradient Ratios
(Using trigonometric calculations - tan = opposite/adjacent)
INCLINE IN
DEGREES
GRADIENT RATIO
OF 1:X
EXAMPLES OF USE OF GRADIENTS IN RELATION TO
ARCHITECTURAL FEATURES (MINIMUM GRADIENT)
7.13
1:8
Ramp
5.71
1:10
4.76
1:12
Ramp
4.09
1:14
Ramp
2.86
1:20
Path
1.91
1:30
1.43
1:40
1.15
1:50
0.95
1:60
0.82
1:70
0.72
1:80
0.64
1:90
0.57
1:100
0.27
1:200
Landing, sideways slope of a path, ramp, car park area, or landing
1:50 to 1:60 shower recess floor
1:70 to 1:80 bathroom floor to the edge of the shower recess
Adapted from “A cheat sheet for converting angle data to gradient ratios”: Trigonometric calculations provided by Tanner, D., Senior Mechanical Engineer of ABB Engineering, 1996 (as cited by Bridge, C. (1996). In Environmental measurement: A handbook for the subject OCCP
5051. The University of Sydney, School of Occupational Therapy and Leisure Sciences, Faculty of Health Sciences, Cumberland Campus,
Lidcombe, Australia. (Chapter 7, pp. 32).
a perimeter scale and, increasingly commonly, the
electronic digital gradient indicator. The former
device is commonly smaller and may therefore need
to be used with a straight edge; it is also prone to
inaccurate readings from parallax error.
Units of measure of these devices are degrees,
percentage, or both. Interconversion of degrees and
percentages, or of either of these and ratios (e.g., 1
in 20 or 1:20), is readily obtainable from websites or
by using published tables such as that in Table 7-2.
Measurement procedure:
Ô Take at least three sets of measurements to
ensure they are accurate and to gain an average reading.
Ô Ensure the measuring devices are well illuminated and that they are appropriately aligned
on the surfaces whose gradients are to be
measured. For example, to determine the verticality of walls, the device should be aligned
vertically; to determine the gradient of a ramp,
the device should be aligned in the direction
of travel (or the intended or most common
direction of travel) and at right angles to it to
establish the cross-fall; to establish the gradient of a four-sided shower floor with four facets
sloping to a drainage outlet, the device should
be aligned along the shortest distance between
the drain and each of the sides (i.e., along a line
from the center of the outlet and at right angles
to each side).
Irregularity of surface gradient is not uncommon and needs careful consideration. Obtaining
several measurements and using a straight edge
enables an average or overall gradient to be determined. However, any localized gradients should also
be measured because gradient irregularities can
impede travel on inclined surfaces. Moreover, two
relevant lengths, or scale, of localized gradient might
need to be considered: that over which a wheel has
to travel in, say, part of its revolution, or the length
corresponding with the wheel base of wheeled
equipment (the distance between the ground contact points of front and rear wheels). Three gradients
may therefore need to be obtained: that of the steepest “small” irregularity on the inclined surface, that
of the steepest “medium” irregularity on the inclined
surface, and the overall or average gradient.
170
Chapter 7
Figure 7-40. Tool to measure lighting levels.
Figure 7-42. Measuring door force.
Gradient is particularly relevant in the design of
ramps. Instructions on how to determine the location and configuration of external ramps can be
found in Appendix D.
Light
Lighting can facilitate a person’s ability to see.
However, if it is not set at the correct level, it
can impede function and eventually damage vision
(Spaulding, 2008b). In an indoor environment, lighting is provided by both ambient and artificial light.
Ambient light can vary, depending on the season of
the year and the time of day. It generally comes from
outside through windows, whereas artificial light is
emitted from fittings such as light bulbs (Spaulding,
2008b).
Lighting must be provided, by natural and/or
artificial light sources, so that there is sufficient
illumination of the activity area but without causing
glare. People vary in their requirements for levels of
illumination and in their sensitivity to glare.
To determine whether lighting levels are adequate, therapists examine lighting levels in different areas of the home where people mobilize and
Figure 7-41. Tool used to measure force.
undertake specific tasks. Measurements are generally taken on stairs and ramps; in entries and hallways; and in kitchens, living areas, bathrooms, and
bedrooms. A light meter is used to measure the level
of lighting, and this is recorded in lux (Figure 7-40).
Recommended lux measures for various areas of the
home may be found in design guides and standards.
Further information on suitable lighting conditions
for people with specific vision impairments should
be sought from vision impairment experts or organizations such as Lighthouse International (www.
lighthouse.org).
When measuring:
Ô Take three readings to ensure data are reliable
and to establish an average measurement.
Ô Take readings at different times of the day when
activities are more likely to occur in the area to
ensure a true reading of variation in lighting.
Ô Be aware that the accuracy of these readings
can vary as a result of daylight and adjacent
reflective surfaces or if the batteries are low.
Ô Place the light meter on the work or viewing
surface. For example, if the task was writing at
a desk, the light meter would be placed flat on
the desk. Where the task is viewing an item on
the wall, the light meter would be placed vertically on the wall (Bridge, 1996).
Force
Force is required to open, hold, or swing features
such as doors, drawers, and windows. Although
door-force gauges are mainly used to measure forces
required to push moving features in the public
access arena, they can also be used in the home
environment if people are experiencing difficulty
with specific features (Figures 7-41 and 7-42). Springload measures are used to measure the amount of
force required to open features such as drawers.
These gauges measure force in newtons and/or
pounds.
Measuring the Person and the Home Environment
When measuring push force:
Ô Place the device at the point on the door where
the force is to be applied.
Ô Move the feature using force uniformly and
slowly, in a consistent horizontal/vertical/
oblique direction as required.
Ô Take three sets of measurements to ensure
reliability and to get an average measurement
(Bridge, 1996).
When measuring pull force:
Ô Position the hook in the middle of the handle on
the drawer where pull force is applied.
Ô Use a perpendicular line of action to gain a
reading at the point of maximal force to stretch
the load measure.
Ô Take measurements three times to ensure reliability and to get an average reading (Bridge,
1996).
Sound
Sound is a combination of either simple or complex
waveforms (Spaulding, 2008b) and, when unwanted
(now called noise), can interfere with how a person
manages in the home environment. Factors affecting
the individual’s response may relate to sound level,
duration of exposure, or frequency of the sound
(Spaulding, 2008b). Sound-level meters are used to
measure noise levels. The formal testing of sound
in the home environment is usually completed by
an ergonomist or acoustic engineer rather than a
therapist.
Recording Measurements of the
Home Environment
Occupational therapists can develop specific
forms to record the information gathered using
tools to measure the built environment or add
the information into existing forms such as the
Comprehensive Assessment and Solution Process
for Aging Residents (Extended Home Living Service,
n.d.).
General Considerations in Measurement
Practice
There may be changes in a person’s measurements and capacity as he or she ages, which might
affect his or her posture, height, hand/arm and leg
strength, body breadth, visual acuity, and weight.
Over time, people might experience changes in their
health and capacities and alterations in the type
or dimensions of the equipment or level of caregiver support they use. Therapists need to anticipate
171
possible changes, accommodate variability in individual performance and household structure, and
adjust measurements accordingly. In some situations
(e.g., with a growing child) therapists will need to
plan regular reviews as the situation changes and
new equipment is required.
Factors Influencing Accuracy of
Measurement
A range of factors influence occupational therapy
measurement practice, including the following:
Ô The competence of the person taking the
measurements
Ô Tool selection use and training
Ô Time allocated for the visit
Ô The nature of the measure or feature
Ô The condition of the measurement tools
Ô The timing of measurement
The Competence of the Person Taking the
Measurements
Measurement error is described as having four
components: error in the measuring equipment
itself, error in locating the landmark or reference
point, error in standardizing the posture of the person or positioning of the measuring tool, and error
in the client’s understanding or response to instructions on adopting the required posture or obstacles
in the environment (Pheasant & Haslegrave, 2006).
To prevent measurement error, occupational therapists need to be competent and well trained in
measurement practice. This includes understanding
measurement practice, knowing how to take accurate measurements, and recording measurements
in a meaningful format. Therapists should ensure
that the measurement process generates consistent,
quality information by using reliable tools and being
comprehensive when gathering and documenting
data.
Tool Selection, Use, and Training
Therapists can use various sophisticated devices and techniques to measure body dimensions,
including calipers, tape scales, weight scales, protractors, and computer-aided anthropometric tools.
Occupational therapists generally do not have
access to such equipment and will need to observe
the client and use a tape measure to measure basic
body dimensions, reach range, and clearances. For
analysis, therapists could also take digital footage of
the client reaching and moving. Alternatively, therapists might want to undertake training in specific
172
Chapter 7
measurement techniques to enhance their competencies in the area.
The environmental measurement tools selected
by therapists generally provide operating instructions. Although this information might be included
when tools are first purchased, it is important that
the therapist checks with people providing any technical design or building advice on how they measure
features in the environment as there is variation in
practice within the design and construction industry. For example, a tape measure is used to check
the height and size of the light switch plate, but the
therapist needs to confirm the reference point for
light switches with an electrician, designer, or building professional.
Time Allocated for the Visit
Therapists must allocate sufficient time for taking
measurements during the visit. This includes time
for measuring the client, their equipment, and carer,
as well as the environment. The therapist will need
to allocate 1 to 2 hours to observe and measure the
client, the equipment, their carer, and the environment depending on the extent of modifications
required. If time is limited at the initial visit, a subsequent appointment might be required to complete
the measurement process. If there are insufficient
resources such as time and money to undertake
repeated measures, therapists are to make sure the
method chosen is valid, has been tested rigorously,
and compares with other measures (Steinfeld &
Danford, 1997). This requires an understanding of
which tool and technique to use in relation to the factors to be measured in the person-environment fit. It
can be time consuming to measure all dimensions of
the existing room, person, caregiver, and all equipment used in the house; however, taking thorough
measurements at the initial visit can reduce the
need for a repeat visit and avoid the difficulties faced
when working with incomplete information.
The Nature of the Measure or Feature
The type of measurements taken by therapists
can include, for example, static measurements of the
client standing and using various postures to reach
or bend or dynamic measurements of the client completing a movement to determine the space or clearance required for the activity. Some features, such as
the diameter of grab bars or handrails or the width
of lips on baths, are difficult to measure accurately
due to the round surface.
The Condition of the Measurement Tools
For accuracy and ease of use, measurement
tools need to be kept in good working order, be
regularly cleaned or calibrated, and, for batterypowered devices, batteries regularly checked or
replaced.
Timing of the Measurement
A person’s performance can vary between different times of the day, week, or season, depending
upon factors such as fatigue, temperature, and the
level and type of illuminance of the environment.
Variance in posture can also occur (Pheasant &
Haslegrave, 2006). Measurements of performance
and posture may therefore also vary, and this should
be considered in deciding upon the time and/or frequency of home visits for measuring purposes. For
example, it may be preferable to visit the client at
the beginning of the day when they have the most
energy for activities, or the therapist may choose
to visit when the client requires considerable assistance during performance of activities and to gather
measurements. There may be variation in space
requirements for the client, their equipment, and
carer during activities with these two circumstances
that need to be considered in planning the home
modification.
Variations in measurement may need to be recorded, with specific reference to those factors influencing the data (Dunn, 2005; Law & Baum, 2005; Law,
Baum, & Dunn, 2005). Knowledge of this variation
can lead to an enhanced understanding of the individual’s specific situation and ensure that the modification is designed to work for the client at all times
(Dunn, 2005).
CONCLUSION
This chapter has provided the reader with information on the role of measurement in improving the
person-environment fit. The contribution of anthropometrics, biomechanics, and ergonomics to measurement practice has been described in addition
to how each is used by occupational therapists to
inform home modification practice. The value of taking an individualized approach to measuring clients
and their home environment has been emphasized,
and the range of tools and resources that are available to assist this process has been described. Also
discussed is the importance of considering the range
of factors that can affect the measurement process.
Although occupational therapists need to work
collaboratively with building industry stakeholders
to understand the building industry’s approach to
measurement of the environment, it is recognized
that design and construction professionals do not
have the expertise to undertake such a technical
Measuring the Person and the Home Environment
and detailed approach in isolation from therapists.
Occupational therapy training in the use of various
tools and measurement techniques continues to be
required for therapists working in home modifications to ensure that clinical reasoning about changes
to the home environment is based on sound evidence rather than guesswork and to ensure an optimal home modification solution for the client.
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Drawing the
Built Environment
8
Elizabeth Ainsworth, MOccThy, Grad Cert Health Sci
and Desleigh de Jonge, MPhil (OccThy), Grad Cert Soc Sci
Measuring the built environment is an important
part of the home modification process to ensure
that there is detail for the planning of environmental
interventions. Once measurements have been taken
of the existing home environment, this information
needs to be put into a format that can be understood
by the person approving the recommendations,
developing the architectural drawings, or undertaking the modification work. Occupational therapists
need to know how to read and use drawings and
have an understanding of their basic components
in order to communicate effectively with others
in the home modification field. Therapists need to
know the different stages of plan development and
the alternative types of plan views and be familiar
with the technical drawing conventions used in the
design profession in order to communicate with
construction personnel. An understanding of how
and when to draw to scale and being familiar with
the various types of drawing tools and technologies
can enhance the professionalism and credibility of
therapists as they work with others in the design and
building profession.
CHAPTER OBJECTIVES
By the end of this chapter, the reader will be able
to:
Ô Describe the purpose of drawings and concept
drawing requirements for occupational therapy
home modification reports
Ô Recognize the value of knowing how to read
drawings and draw using various tools and
technologies
Ô Describe the range of tools and resources available for developing concept drawings
Ô Recognize the importance of clear documentation to inform the work of the design and/or
construction professional
RECORDING ENVIRONMENTAL
MEASUREMENT INFORMATION
The Purpose of Drawings
Drawings are a means of communicating ideas
to all parties involved in the planning, design, and
construction of the building represented. These
ideas are set out in a pictorial format that incorporates spaces filled with shapes and objects (Housing
Industry Association & Illaring Pty Ltd., 2006). Being
the language of the building design and construction
industry, drawings are used to visualize possibilities,
study alternatives, and present design ideas about
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Guide to Home Modification Practice, Second Edition (pp. 175-194).
© 2019 SLACK Incorporated.
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Chapter 8
the form and spaces of a building (Ching & Eckler,
2013). To be useful for this purpose, they need to be
clear, consistent, easy to comprehend, and free of
ambiguity for the reader.
Occupational therapy drawings are not architectural drawings because therapists do not have
professional training in this field. Rather, therapists
develop concept drawings to clearly detail what is
required for the home modification and to complement the individual’s background information and
the proposed scope of works in their report. Concept
drawings describe the basic design and modification
elements and approximate dimensions in the current
and proposed home environment using basic technical drawing conventions. Depending on the type and
complexity of the home modification work, concept
drawings can be drawn by hand or developed using
basic computer software. Concept drawings differ
from architectural drawings, which are more precise
and detailed and adhere to strict technical drawing
conventions. Concept drawings do not contain the
same level of detail, but rather provide an overview
of the basic layout of spaces, fittings and fixtures
and their associated dimensions.
Concept drawings are used to communicate with a
broad range of people from a variety of backgrounds
and interests in the home modification process.
These people include clients, other health professionals, people involved in the design and construction industry, and staff in organizations providing
funding for the modifications. Primarily, these drawings are used by occupational therapists to describe
clients’ requirements; however, they are often used
as the basis of the tendering and quoting process for
home modifications where the work is small in size
and able to be installed by people who may or may
not be registered tradespersons, or for the development of more detailed architectural drawings
where home modifications are complex and need
to be installed by registered building professionals.
Concept drawings can provide a foundation for the
following:
Ô Communicating the intent of the building work
Ô Discussing design and modification proposals
and issues
Ô Illustrating proposed changes or variations to
the building work
When minor changes are required to be made to
the design, these alterations can be put in writing in
a report and noted directly on the drawing; however,
if major changes are needed, a new set of drawings is usually developed. This allows the design to
evolve and the final option to be documented clearly.
Concept drawings also serve as a useful audit tool
during and after the home modification works have
been completed to ensure that the work has been
done as planned by the design and/or building professional.
Resources to Assist Drawing
Practice
Organizations such as the International
Organization for Standardization, American National
Standards Institute (ANSI), Standards Australia,
the British Standards Institution, and the Canadian
Standards Association establish common practice
across the industry and contribute to the development of rules or manuals for the preparation and
presentation of drawing documents. These standards describe the technical drawing conventions
used in drawings to denote the overall layout of the
design and the various features in the built environment.
Textbooks by Bielefeld and Skiba (2013); Ching
(2015); Ching and Eckler (2013); Clutton, Grisbrooke,
and Pengelly (2006); Thorpe (1994); and Yee (2012)
and online resources can also be used to guide occupational therapy drawing practice. These books and
online resources include recommendations for drawing practice relating to dimensioning, lines, symbols,
abbreviations, scales, layout of drawing sheets, orientation of drawings, architectural conventions for
cross-referencing drawings, coordinates, grids, and
material representation. They also provide architects, building designers, contractors, and occupational therapists with information about methods
of presenting drawings before, during, and after the
modification of a building.
READING
AND
UNDERSTANDING DRAWINGS
Development of Architectural
Drawings
Reading and understanding the different types of
architectural drawings enables occupational therapists to communicate more efficiently and effectively with design and construction professionals.
Once therapists learn the language and practice
of the design and construction industry, they can
critically appraise plans to assess their suitability in
relation to the design needs of their clients (Ashlee,
Clutton, Pengelly, & Cowderoy, 2006). This ensures
the person-environment fit as described in previous
chapters.
Drawing the Built Environment
177
There are three types of architectural drawings in
home modification practice that therapists are likely
to encounter and need to be able to read and understand: sketch design drawings, developed design
drawings, and working drawings.
Sketch Design Drawings
Sketch design drawings are simple or quickly executed drawings representing the essential features
of an object or scene. Lacking detail, they are often
used as a preliminary study (Ching, 2015). In outline
form, these drawings depict the designer’s general
intention. They give an overall picture of the scheme
but do not show constructional details and are usually prepared early in the development of a design
with the aim to give those involved some general
information on how things ultimately go together in
the bigger picture. These plans indicate space but
do not provide significant detail or dimensions. An
occupational therapist, architect, or builder might
do a range of sketch drawings of a room or area
of the house to show the client how the various
features might be laid out (Figure 8-1). This type
of drawing can stimulate discussion about different
design layouts to create the best possible option for
the area being built or modified.
Figure 8-1. Sketch drawing of a bathroom floor plan, not to
scale. The measurement on top of the line is in inches (imperial
measurement), and the measurement below the line is in millimeters (metric measurement).
Developed Design Drawings
Developed design drawings are more complex
than sketch design drawings and are usually completed by an architect or licensed building contractor. These drawings provide detailed information
about the overall layout of the built environment and
the relationships of the spaces within and around
the building. They can include, for example, illustrations of furniture placement and other features
within and around the home and equipment turning
circles using specific technical design conventions.
The plans include specific illustrations and technical design conventions but are not as developed as
those used at the working drawing stage. They are
more pictorial than technical in nature and are less
likely to feature the drawing conventions of the working drawings that are produced for construction or
modification work.
Sketch designs and developed design drawings
are often done freehand or, if computer generated,
are presented to appear freehand. The reader may
feel more comfortable offering feedback if drawings
are “only” freehand than if they have the “firmed up”
look of technically drafted drawings.
Working Drawings
Working drawings show, in graphical or pictorial form, the design, location, dimensions, and
relationships of elements of a building (Ching, 2015).
They describe the constituent parts of a building,
articulate their relationships, and reveal how they go
together (Ching & Eckler, 2013). Using different technical drawing conventions than those of developed
drawings, working drawings are usually developed
by the architect or licensed building designer and
are used to guide contractors as they undertake the
building work (Figure 8-2). For example, developed
drawings might show an illustration of a bathroom
in pictorial form using simple lines, whereas working
drawings would be more technical and use specific
lines to represent the features in this area in more
detail on the plan.
There are usually various sets of drawings at this
stage, each describing in detail different aspects of
the design, such as site plans, floor plans, elevations,
sections, and drainage plans. Such complex drawings are usually drawn using drafting equipment or
computer software rather than freehand.
Plan Documentation Process for
Home Modification Work
Drawings can be documented and classified
according to the type of information presented. A
design process for home modifications might include
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Chapter 8
common drawing types designers use to communicate their design ideas are plans, elevations, and sections (Wang, 1996). These are the drawings through
which most buildings can be read, and they make
up one part of a whole series of documentation that
describes a building in detail (Dernie, 2014).
Occupational therapists use plan, elevation, and
section views in their concept drawings, depending
on the size and complexity of the home modification
work to be undertaken and the amount of detail to be
provided for design or construction professionals.
For example:
Ô An elevation might be drawn for the installation
of a grab bar beside the toilet.
Ô An elevation and floor plan view might be
drawn for a bathroom undergoing extensive
home modifications.
Ô A section might be drawn of a set of stairs or a
vanity to illustrate the location of the shelving
in the cupboard.
Site Plan
Figure 8-2. Working drawing of a bathroom floor plan. The
measurement on top of the line is in inches (imperial measurement), and the measurement below the line is in millimeters
(metric measurement).
the development of sketch and/or working drawings
for the tender, quoting, and construction processes
(Wang, 1996).
Because home modification work can be extensive, costly, and time consuming to draw to scale, it
is preferable that occupational therapists and clients
rely on an architect or building designer for these
complex drawings. The completion of drawings by
an architect or building designer may be a mandatory requirement under legislation, depending on
the nature and extent of work to be completed. This
practice needs to be checked with local authorities
to ensure that therapists who choose to do their
own drawings are not operating outside their area of
professional expertise or beyond the extent of their
qualifications.
TYPES
OF
VIEWS USED
IN
DRAWINGS
Various types of views can be incorporated into
the drawings to understand and depict the total 3D
configuration of the built environment. The most
The site plan is a view looking down on a site
from above, illustrating location and orientation of
the building on a parcel of land, and providing information about the site’s topography, landscaping,
utilities, and site work (Ching & Eckler, 2013). The
site plan also details site boundaries and the location of the street, paths, and existing and adjacent
buildings. There are various styles of lines used in
drawings (e.g., thick lines to denote the external
walls of the home and covered outdoor areas; thinner lines to represent the planted areas, pavements,
and driveways; and dotted lines to indicate the line
of the roof of the building).
From the site plan, a reader can glean the indoor/
outdoor relationship between the landscape and the
building and the orientation of the building in relation to the direction of the sunrise and sunset and
the prevailing breezes, as well as location in relation
to structures or features on the site and adjacent to
the site (Figure 8-3). Features on the site may include
trees and permanent structures such as separate
car parking facilities, storage facilities, and boundary fencing. Structures adjacent to the site may
include trees and buildings occupied by neighbors
and local council structures such as electricity poles
and paths.
Floor Plan
Of all of the working drawings, the floor plan is
one of the most important because it includes the
Drawing the Built Environment
179
Figure 8-3. Site plan.
Figure 8-4. Example of the floor plan of a domestic home.
Elevation
An elevation is a horizontal or side view of a
building’s interior or exterior, usually taken from a
point of view perpendicular to the principal vertical
surfaces. It illustrates the size, shape, and materials
of the interior or exterior surfaces, as well as the
size, proportion, and nature of the door and window openings in the design (Ching & Eckler, 2013).
Elevations show distance, length, width, and height
dimensions of areas and features and are named by
the direction they face (e.g., a north elevation faces
north). Internal elevations may be cross-referenced
and named through a diagram on the floor plan (e.g.,
four arrows labeled A to D in the center of the floor
plan can each point to four internal walls represented in the corresponding elevation view; Figures 8-5
through 8-10).
Figure 8-5. Bathroom floor plan.
greatest amount of information. It is a sectional
drawing obtained by passing an imaginary cutting
plane through the walls above the floor, usually
at a height that allows windows to be located. The
floor plan is a view looking down from above, and
it illustrates the dimensions of a building’s spaces,
as well as the thickness and construction of the
vertical walls and columns that define these spaces
(Figure 8-4). Among other features, it will show the
building layout, room sizes, door and window placement, and bathroom and kitchen design (Ching &
Eckler, 2013). The floor plan illustrates distance,
circulation space, width, depth, length of areas, and
features (see Figure 8-4).
Section
A building section is a cross-sectional or horizontal view after a vertical plane is cut through a
building and the front portion is removed. It reveals
the vertical and, in one direction, the horizontal
dimensions of a building’s spaces and can illustrate
the thickness of floors, roofs, and walls. Sections can
also include exterior and interior elevations seen
beyond the plane of the cut (Figure 8-11; Ching &
Eckler, 2013).
Overall, sections add depth and meaning to the
drawings, as well as interest. These types of drawings can take on a variety of appearances due to the
evolutionary nature of the design process (Wang,
1996).
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Chapter 8
Figure 8-6. Bathroom, elevation A.
Figure 8-7. Bathroom, elevation B.
Figure 8-8. Bathroom, elevation C.
Figure 8-9. Bathroom, elevation D.
Figure 8-10. External house elevation.
Drawing the Built Environment
181
SPECIFICATIONS
Once finalized, plans form the basis from which
the agreed building work is undertaken. They can
be used with, or as an alternative to, a written specification (Ashlee et al., 2006). Because drawings in
themselves might not convey all of the information,
written specifications can be developed to provide
a detailed description of the technical nature of the
materials, standards, and quality of execution of the
work. The specifications are a business document,
a contract document, and a working document, and
they serve a diversity of readers (Standen, 1995).
They provide the following:
Ô Evidence to the person paying for the construction or modification that the building will
include his or her requirements
Ô Information on items to be priced that are not
indicated on the drawings
Ô A record of what has been built or modified
Ô A reference during inspections to check that
the correct products, designs, and features
have been incorporated into the design or
modification (Standen, 1995)
The drawings should be used to show whatever
is best displayed by the drawings, and the specification should be used to communicate information
that is best described by words (Standen, 1995). By
way of example, a drawing might indicate the need
for tiles in a bathroom and the pattern in which they
are to be laid. A specification will identify the tile
manufacturer, the color, the slip resistance when
wet or dry for pedestrians walking on the product,
the method of installation, and the type and color
of the grout. The specification can be prepared by
a builder, engineer, architect, or licensed building
designer to advise a contractor about the materials
and workmanship that is expected and that cannot
be displayed on the plans.
Access standards can be referred to in a specification to direct the reader to review the most
appropriate section of the standards when completing the construction or modification. It is essential
that occupational therapists and the reader of the
specification understand the application and intent
of the access standards to ensure that they are
referenced appropriately during the design and
modification process. If the therapist is requesting
complex or extensive home modifications, a design
or construction professional might be required to
develop a detailed building specification to provide
the required level of technical detail for quoting
and construction purposes. If required, therapists
Figure 8-11. Stairs. Section view. The measurement on top of
the line is in inches (imperial measurement), and the measurement below the line is in millimeters (metric measurement).
should refer the design and construction professional to specific figures or clauses in the access
standards that describe the specific performance
criteria for products and building work.
UNDERSTANDING SCALE
The aim of scale drawings are to prevent confusion and to ensure consistent documentation of
information for use by design and construction
professionals. They are drawn to conventions, with
design features such as walls, doors, windows, and
stairs, that will look the same on different plans for
different buildings.
Scale drawings allow therapists to examine the
layout, dimensions, and spaces in the drawing to
determine whether the person (the caregiver and/
or the equipment he or she uses) can move between
buildings and external areas or into and within the
home and utilize the space, fittings, and fixtures
effectively. It is a means of transferring or reducing
information from actual size to a more convenient
size with which to work and represent on a suitably
proportioned piece of paper (Ashlee et al., 2006).
Scales are used to accurately reproduce a large
object on a sheet of paper in its correct proportions.
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Chapter 8
Table 8-1. Common Scales Used in Architectural Plans
TYPES OF DRAWINGS
Site or dwelling floor plan
Floor plan of a room (for example, a bathroom, kitchen, or bedroom)
Scale uses a ratio to show the size of a real object in
relation to the size of the drawn object. A full-size
drawing is one with a scale ratio of 1:1 (International
Organization for Standardization, 1979). The scale
chosen for the drawn object depends on the size of
the real object, the amount of detail required, the
complexity of the object, the purpose of the presentation (International Organization for Standardization,
1979), and the size of the piece of paper being used
(Ashlee et al., 2006).
Drawings will indicate both scale and unit of measurement in either imperial or metric language. For
example, 1/4 in equals 1 for 12 in (1/4” = 1’0” indicates
that the real object is 48 times larger [1:48] than the
drawn object, or in metric 1:50 indicates that the real
object is 50 times larger than the drawn object).
Architectural scales used in the United States
are generally grouped in pairs using the same dualnumbered index line, including the following:
3” = 1’0” (ratio equivalent 1:4)
1 1/2” = 1’0” (1:8)
1” = 1’0” (1:12)
1/2” = 1’0” (1:24)
3/4” = 1’0” (1:16)
3/8” = 1’0” (1:32)
1/4” = 1’0” (1:48)
1/8” = 1’0” (1:96)
3/16” = 1’0” (1:64)
3/32” = 1’0” (1:128)
In the United Kingdom, Canada, and Australia, the
architectural scales are as follows:
Ô 1:1/1:10
Ô 1:2/1:20
Ô 1:5/1:50
Ô 1:100/1:200
Scale changes might occur between section and
elevation drawings. Table 8-1 shows common scales
used in architectural plans.
Small or detailed objects, such as a door sill or
door furniture, are often drawn to a larger scale
ratio (e.g., 1 1/2” = 1’0” [1:10] or larger). The detail on
the larger scale drawing takes precedence or overrides the detail on the smaller scale drawing of the
same area or object. For example, the detail in the
floor plan area of the bathroom (1/2” = 1’0” or 1:20)
IMPERIAL
METRIC
3/16" = 1’0”
1:100
1/4" = 1’0”
1:50
1/2" = 1’0”
1:20
overrides the detail provided for the same bathroom
as drawn in the floor plan of the house or apartment
(3/16” = 1’0” or 1:100). The scale 1/2” = 1’0” or 1:20 is
a “larger” scale than 3/16” = 1’0” or 1:100 because
the drawing itself is larger than the same object
(Figures 8-12 and 8-13).
TECHNICAL DRAWING
CONVENTIONS
To read a plan, occupational therapists need to
understand how objects are illustrated and labeled.
This involves understanding the technical drawing conventions and symbols that are used by the
design or construction professional to describe the
building design (Weidhaas, 2002). Technical drawing standards contain specific information about
the conventions and symbols, and they are used by
the building and construction industry. Ensuring
that design and construction professionals use the
same terminology and symbols assists in establishing common design and construction practice. The
technical drawing standards are not a mandatory
requirement for architectural drawings, but they are
a useful guide. Publications such as International
Organization for Standardization standards, access
standards (e.g., ICC/ANSI A117.1 [ANSI, 2009]) or
architectural books (Bielefeld & Skiba, 2013; Ching,
2015; Ching & Eckler, 2013) and online resources set
out examples of technical drawing conventions and
symbols that occupational therapists can use as a
guide when they develop concept drawings. In many
instances, design and building professionals might
further stylize the basic elements described in the
technical drawing standards to increase the readability and attractiveness of the image.
Technical drawing standards may contain basic
conventions (e.g., dimension lines [Table 8-2] and
symbols for architectural features [Figure 8-14]).
These conventions and symbols vary because there
is no set requirement for them to be drawn a specific
way.
Drawing the Built Environment
183
Figure 8-12. Example of scales
(metric).
Figure 8-13. Examples of floor plan
views drawn at different scales.
Figure 8-14. Examples of symbols
for toilets.
Lines
The basic graphic symbol for all drawings is the
line, which defines spatial edges, renders volume,
creates textures, and connects to form words and
numbers (Wang, 1996). Creating lines is a major
element of a drawing, and good line work is critical to the development of an accurate and neat
drawing (Bielefeld & Skiba, 2013; Housing Industry
Association & Illaring Pty Ltd., 2006). Line work in
plan, elevation, and section views should be sharp,
dense, of uniform width, and consistent for the purpose of legibility (Wang, 1996). The specific types
and thickness of each line and their application
are often set out in technical drawing standards or
textbooks. There are common line and dimensioning
standards for home design (Figure 8-15).
Six major types of lines are used in drawings that
have specific meanings:
1. Visible object line: A solid line representing the
contour of an object or the visible edges
2. Hidden object line: Hidden or unseen objects
below or in front of the reader
3. Dimension: A line terminated by arrows, short
slashes, or dots indicating the extent or magnitude of a part or whole along which dimensions
are scaled and indicated
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Chapter 8
Table 8-2. Examples of Conventions
CONVENTION
DESCRIPTION
Min
Minimum
Max
Maximum
>
Greater than
≥
Greater than or equal to
<
Less than
≤
Less than or equal to
Boundary of clear floor space
or maneuvering clearance
Figure 8-15. Types of lines used in plans or drawings.
Center line
Direction of travel or approach
Location zone of element,
control, or feature
Graphic convention for figures from American National Standards
Institute. (2009). ICC/ANSI A117.1-2009: Accessible and usable buildings and facilities. New York: Author.
4. Center line: A broken line with relatively long
segments separated by single dashes and dots
to represent the axis of a symmetrical element
or composition
5. Break line: Broken line segments joined by
short zigzag strokes to show a portion of the
drawing that has been cut off
6. Overhead line: Hidden or unseen objects
behind or above the observer (Ching, 2015)
Dimensioning
Dimensions are used on drawings in conjunction
with dimension lines to denote the length, height,
or width of the object being represented. Although
the imperial system of measurement is commonly
used in the United States, a combination of metric and imperial measurements is generally noted
in various U.S. design standards. When imperial
dimensions are used, they are expressed as feet and
inches, whereas metric dimensions are expressed in
millimeters (mm), never centimeters (cm). In some
instances, dimensions may be written in meters (e.g.,
1.50 m), particularly at the sketch and developed
design stages. The actual dimension number is conventionally written along the lines and placed above
it (Figures 8-16 and 8-17; Bielefeld & Skiba, 2013).
Figure 8-16. Dimension line that shows imperial and metric
measurements.
Creating Concept Drawings
Design or construction professionals undergo
specific technical drawing training to develop the
skills to create drawings that are technically sound
and provide significant construction detail. These
drawings have a technical detail and accuracy that
cannot be achieved by therapists who have not had
formal technical drawing training.
Therapists can create preliminary or concept
sketch drawings to develop design ideas for home
modifications in advance of an architect or building
designer’s more detailed drawings. If therapists want
to incorporate more developed drawings into their
reports, they should refer the work to a design professional. If they would like to become skilled in any
of these forms of drawing, they need to undertake
formal training in architectural drawing.
CONCEPT DRAWING
INFORMATION PROVIDED TO
DESIGN AND CONSTRUCTION
PROFESSIONALS
Concept drawings provide more detail to the written wording that is contained in the occupational
therapy report. If home modification work is simple
and straightforward to undertake, such as the installation of grab rails, handrails, stairs, or small ramps,
Drawing the Built Environment
A
B
C
D
185
E
Figure 8-17. Where to position dimension lines and measurements on plans and drawings. The measurement on top of the
line is in inches (imperial measurement), and the measurement
below the line is in millimeters (metric measurement). (A) Toilet
floor plan; (B) toilet elevation; (C) vanity floor plan; (D) vanity
elevation; (E) bath floor plan; (F) bath elevation; (G) stairs elevation. (continued)
186
Chapter 8
F
G
Figure 8-17 (continued). Where to position dimension lines and measurements on plans and drawings. The measurement on top of
the line is in inches (imperial measurement), and the measurement below the line is in millimeters (metric measurement). (A) Toilet
floor plan; (B) toilet elevation; (C) vanity floor plan; (D) vanity elevation; (E) bath floor plan; (F) bath elevation; (G) stairs elevation.
a concept drawing may be sufficient to guide the
builder. This concept drawing needs to have a written scope of works to accompany the illustration to
ensure there is sufficient information for the modification. If the home modification work is complex,
such as the renovation of the bathroom or kitchen
or the installation of a lift, lengthy ramp, or additional room, the concept drawing may be used as
the basis for a more detailed technical drawing and
written specification that is completed by the design
or construction professional. It is sometimes helpful
to include photos and drawings of the existing areas
to be modified as well as the drawing of the proposed changes to provide the design or construction
professional with a more comprehensive picture of
the area, particularly if they are developing a more
detailed technical drawing for the proposed home
modifications. The provision of photos and drawings
ensures that the design or construction professional
is able to clearly visualize the area to be modified
and use these illustrations for ongoing reference during the drawing and modification stages of the work.
When to Draw to Scale
Drawings of minor modifications, such as grab
bar installations and handrails on stairs, do not
generally need to be drawn to scale. If they are not
drawn to scale, this should be noted on the drawing.
However, the figures should always be proportionate
to ensure that the reader has a good understanding
of the relationship of items and areas in relation to
one another. When developing drawings for a major
modification, scale drawings enable occupational therapists to determine which fittings, fixtures,
equipment, or furniture can reasonably fit into a
room and whether the space is adequate for items
to be placed and for the circulation of individuals
with and without their equipment. Scale drawings
can also be used to indicate the precise location and
assess the ease of access to, and use of, existing fixtures, such as doors and windows. However, drawing
to scale is time consuming because it requires that
relevant dimensions of the person, their caregiver
and equipment, and the existing home environment
are accurately measured and then translated into a
scale drawing.
Drawing on Photographs
Drawings may be done on a photograph of an
area or feature by hand or by computer, and it is
advisable that occupational therapists complete
an accompanying concept drawing that is either to
scale or not to scale depending on the complexity of
the work. The provision of the photo and line drawing for the one area ensures that the building professional has adequate information for completion of
the home modification that is not open to interpretation. Drawings on a photo may be problematic if the
photo is not clear or if the photo has been taken at
an angle.
DRAWING
BY
HAND
Although drawing can be completed with the
assistance of computer technology, therapists can
make concept drawings by hand quickly and easily if
they are skilled in drawing. They can translate measurements of clients, their equipment and caregiver,
and the home environment into a simple concept
Drawing the Built Environment
drawing, particularly if computer technology is
unavailable. However, drawings developed by hand
using pencils, rulers, scale rulers, pens, and paper
are often labor intensive and take significant time.
These drawings can also vary in quality, depending
on the skills of the person completing the drawings
and the type of equipment used. They cannot be
edited, saved, or adjusted as easily as computerassisted drafting (CAD) or computer-assisted drawings (e.g., Microsoft Word, PowerPoint, Visio, Idapt
Planning [www.idapt-planning.co.uk], or OT Draw
[www.OTdraw.com] drawings).
Tools for Drawing by Hand
Hand drawing can be completed with the aid
of drafting equipment, such as a drafting board,
squares, rulers, scale rulers, and other tools, for the
systematic representation and dimensional specification of architectural features in the home (Bielefeld
& Skiba, 2013; Ching, 2015). Quality equipment and
materials make the act of drawing a more enjoyable
experience, and the achievement of quality work
becomes much easier in the long term (Ching, 2015).
The equipment and materials need to be good quality, clean, and appropriate to the task. The following
items can be used by therapists when hand drawing,
including paper, pencils, pens, templates, scale ruler,
set square, or T-square.
Paper
Various types of paper can be used when doing
concept drawings: plain paper, graph paper, and
drafting film. Although plain paper is the medium
most regularly used by occupational therapists,
they might need to talk to representatives from local
drawing and drafting companies about the most
appropriate paper for their drawing requirements.
Sketch-grade paper is suitable for quick sketches
and overlays on drawings where alternative layouts
are being developed. For a quality finish to a concept
drawing, drafting film is used. It is translucent and
has a matte textured surface on one side and a plain,
smooth textured surface on the other. It resists
humidity that can affect the sheet size because it is
made of a plastic that is more dimensionally stable.
Although it is more expensive and resists tearing, it
is also “harder” on equipment (e.g., pens wear out
more quickly). Grid paper is also useful if drawings
are being done to scale, as the grid can come in various scale sizes. It provides therapists with a good
visual guide during drawing. The grid paper has the
disadvantage of having extra lines compared to the
drafting film, making concept drawings look “busy”
when drawn directly onto this grid paper. The drafting film can be placed on top of the drafting paper
187
and the concept drawing done on the film to create a
less cluttered drawing.
Pencils
The most common pencils used for drawing are
2H and H (hard), F or HB (medium), and B (soft).
Often, 2B (or even softer) pencils are used for sketches (the B stands for black). The choice of pencil
depends on the user’s preference and drawing skills.
Sharp pencils or propelling (clutch) pencils using a
narrow lead are ideal for drafting. These enable the
user to continue drawing without having to stop and
sharpen the tool. A soft eraser is also essential to
clean markings off of the drawing sheets.
Pens
Final concept drawings should always be in ink or
pen. Although pencil may be used initially to draw
the lines, once complete, they should be drawn over
in ink or felt pen. Felt-tipped technical drafting pens
are available in various thicknesses and are generally used to draw specific line widths. Ballpoint pens
are not appropriate for drawing work because the
lines produced by these types of pen are not clean
and clear on paper.
Templates and Other Drawing Tools
Templates and a compass can save time when
drawing. Templates are generally made of plastic
and have geometric shapes and shapes of plumbing
fixtures and furnishings. They also have lettering,
numerals, and other symbols, all of which can provide a guide for drawing objects accurately and to
scale. Circles are drawn with a pair of compasses.
Scale Ruler and Set Square or T-Square
Scale rulers are used to draw in a precise ratio to
the original (Housing Industry Association & Illaring
Pty Ltd., 2006). These rulers vary in style, quality,
and scale. There are common scales used for specific plans. As indicated previously, common scales
used by therapists when drawing include 3/16” = 1’0”
(1:100); 1/4” = 1’0” (1:50) for site or dwelling floor
plans; and 1/2” = 1’0” (1:20) for floor plans of rooms or
for internal elevations. Scale rulers also vary in style
(Figures 8-18 and 8-19).
Scale rulers need to be kept clean by washing
with a mild soap and water. Ideally, they should only
be used to measure drawings and not to draw lines
because scale rulers become worn and the divisions
of the scale can affect the quality of the line drawn.
Routinely, a set square or T-square is used to rule
lines. Scale rulers should not be used as a cutting
edge or be used with color markers because these
will destroy the edge and markings.
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Chapter 8
Figure 8-18. A flat scale ruler does not hold to the paper tightly
unless the user tilts the ruler to the paper.
Drafting Board
This is a flat working surface to which paper can
be secured with clips or tape. Drafting boards vary
in size but should be at least 25% larger than the
largest piece of paper that will be regularly used on
the board (Housing Industry Association & Illaring
Pty Ltd., 2006). The paper is attached to the board
so that it sits squarely to a T-square or straight-edge
or, if preprinted, the border is used to square up
the paper (Housing Industry Association & Illaring
Pty Ltd., 2006). Plastic drafting boards with parallel rules will generally suit occupational therapists’
drawing needs.
Square
The T-square is held firm on one edge of the
drafting board (e.g., to the left) and can move up
and down on the page to draw horizontal lines. The
T-square can also be used as a surface against which
to place set squares to create vertical and angled
lines. Most drafting boards have sliding rulers in
place of the T-square (Housing Industry Association
& Illaring Pty Ltd., 2006). The clear plastic T-square
enables the user to see through to the paper.
Set Squares
Set squares are manufactured from clear plastic,
and the most commonly used in home modification
drawing are those that are 45/45/90 degrees and
60/30/90 degrees to assist with drawing angled and
horizontal or vertical lines.
The Drawing Process
The process for completing a concept drawing
includes the following:
Ô Selecting the view(s) to be drawn
Ô Choosing the paper type and size
Figure 8-19. A different type of scale ruler that grips the paper
tightly.
Ô Drawing the view(s)
Ô Checking that all information included in the
concept drawing is accurate
Ô Providing the title block on the right side or
bottom of the page
Ô Dating and signing the drawing
The concept drawing might need to include a
range of different views of the area to be modified
(e.g., the floor plan to show distance, circulation
space, width, depth, and length and the elevation
view to show distance, heights, width, and length).
Occupational therapists should ensure that each different view, or plan, of the same area contains consistent information. In particular, the measurements
need to be compared to ensure that there are no
discrepancies between the drawings. For example,
the location of the grab bar beside the toilet—the
distance from the back wall (e.g., cistern wall)—in
the floor plan view needs to be identical to its location in the elevation view.
Before starting their final scale concept drawings, occupational therapists might sketch them out
roughly on a piece of paper first. This allows them to
get a clear picture in their mind of what they want
to draw. For concept drawings that are not drawn to
scale, they can draw directly onto white paper, using
a black pen to build on the final pencil drawings.
All lines should be drawn using a ruler, and figures
should be recognizable using conventional symbols,
be clearly labeled, and be in proportion. If drawing
to scale, therapists need to select an appropriately
sized scale for the area being drawn, as per the earlier discussion on scale. For example, a floor plan of
a bathroom may be drawn 1/2” = 1’0” or 1:20.
There are three different ways of completing the
scale concept drawing using the pens or pencils and
various types of paper (Figure 8-20):
Drawing the Built Environment
A
189
B
C
Figure 8-20. Paper options for concept drawings. (A) Using drafting paper for drawings. (B) Combining drafting paper on top of grid
paper for drawings. (C) Using grid paper for drawings.
1. Therapists can draw directly onto white paper
or drafting film using a pencil or pen. The drafting film illustration can be photocopied onto
white paper when finished.
2. Therapists can lay drafting film over grid paper,
which has been set out according to a scale, to
guide their drawings, using pencil and pen and
a scale ruler as described previously. The grid
paper provides therapists with an inbuilt reference scale during the drafting process. It helps
correct alignment of features within the drawing and the whole drawing itself, and guides
them as they use their ruler (International
Organization for Standardization, 1979). A
cross-check of the scale ruler against the grid
paper that is positioned under the drafting film
can be done during the drawing process. Space
needs to be left around the drawing for listing
lines and measurements, which requires that
the drafting film be offset from the grid paper.
3. Therapists can draw directly onto grid paper.
When drawing a room, therapists first outline
the overall shape of the area (e.g., the walls, windows, and doors). All permanent fixtures or fittings
are then drawn in their respective locations using
appropriate conventions and symbols, starting with
the larger items and working down to the smaller.
For example, a drawing of a bathroom would include
bath/shower, vanity, toilet, taps, spouts/shower
roses, soap/toilet roll holder, light switches, electrical fittings, and power outlets. Dimension lines are
then drawn on the outside of the drawing in line with
the items they are representing. This ensures that
the inside of the drawing remains uncluttered and
clear. The smaller dimensions are usually recorded
closest to the outside of the drawing, with dimensions increasing incrementally away from the drawing. This creates a hierarchy of dimensions. The area
drawn can be divided horizontally and vertically to
guide the set of the dimension lines (Figure 8-21).
When divided horizontally, dimension lines with
measurements are to match the items in the top and
bottom halves of the drawing and located either
above or below the drawing to match the half of the
drawing they reference. When divided vertically, the
dimension lines with measurements are to match
the right and left halves of the drawing and located
either to the right or left of the drawing the measurements reference. Further, the dimension lines should
be written in such a way that the page is turned
only once (e.g., clockwise) to read the figures on the
dimension lines along the top, bottom, and sides of
the drawing (see Figure 8-21).
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Chapter 8
Figure 8-21. Floor plan of a bathroom area showing the horizontal and vertical division of the illustration to guide the set-out of
measurements and dimension lines. The measurement on top of the line is in inches (imperial measurement), and the measurement
below the line is in millimeters (metric measurement).
Drawings are initially developed using pencil.
Once the drawing has been finalized, pencil lines are
built on using a felt-tip pen, and the pencil lines are
removed with a soft rubber eraser.
When developing a drawing, therapists should
be mindful to include all of the required information in the drawing, such as the permanent fittings
and fixtures and accompanying recommendations.
For example, in an elevation of a grab bar on a wall,
essential elements include the following:
Ô Configuration of bar
Ô Diameter of bar
Ô Length of bar
Ô Height of bar above floor level
Ô Wall the bar is to be located on
Ô Distance of end of the bar from the back wall
(e.g., distance on the wall next to the toilet adjacent cistern wall)
Ô Structure/surface of mounting wall
Ô Whether studs have been located
Ô Other elements described in the standards that
are relevant to the client’s specific requirements
A title block may be included at the side or bottom of the page to enable all relevant details about
the drawing to be recorded, including the client’s
name and address, project name/type, the name
of the area, the type of view, whether the drawing
has been drawn to scale and the size of the scale,
Drawing the Built Environment
the page number or set total, the date of drawing,
the review date and/or number, and the name of the
designer/draftsman/occupational therapist (Housing
Industry Association & Illaring Pty Ltd., 2006). Other
information can include the name of the area drawn,
the type of view (e.g., the floor plan view or elevation), the scale, and whether measurements are in
feet and inches or millimeters if the abbreviation for
these measurements is not included with the dimensions. A title block at the bottom of the page or on
the right side of the page allows large sheets to be
folded into sections and clipped to the left, and the
drawing remains easy to read. For future reference,
the occupational therapist should sign and date
plans to provide evidence of the authorship and the
date they were finalized.
Lettering on Hand Drawings
Therapists are required to incorporate neat lettering into their drawings to ensure that items are
clearly labeled and the document is professionally
presented. Some of the most important characteristics of a lettering style are readability and consistency in both style and spacing (Ching, 2015). Skillful
lettering enhances the appearance and clarity of
the drawing, whereas poor lettering can be difficult
to read and can detract from the drawing. Lettering
needs to be consistent, dark, crisp, and sharp for the
best presentation. It can be in pencil, spaced equally
to the height of letters, and finished in pen. Lettering
must be neat, brief, straight, and completed horizontally on drawings. It is not to be placed over part
of a space or a drawn object. Numerals are to be
placed outside the view shown to ensure the drawing
remains uncluttered.
Therapists can find more information on the
placement of lettering and lines from local architects
or building designers, through completing an architectural drawing course, or by referring to texts such
as books by Ching (2015) or by checking resources
online.
DRAWING USING
COMPUTER TECHNOLOGY
In order to anticipate expected changes, home
modification documents need to be flexible, time
efficient to create, and inexpensive to revise (Wang,
1996). To accommodate minor changes and to avoid
redrawing the entire sheet of documentation, Wang
(1996) notes that computer technology has become
popular in preparing drawings.
191
Computer Tools for Drawing
Once these tools are mastered, drawings using
computer technology are faster to draw, store, and
retrieve. They can be created using drawing features
in existing business software, such as Microsoft
Word and Microsoft PowerPoint; general drawing
programs such as Paint and VisioPro; dedicated
CAD software of varying levels of sophistication
(e.g., AutoCad, Autosketch, SmartDraw, and Google
Sketch-Up); or specific software for use by health
and other professionals such as Idapt Planning,
and OT Draw (Figure 8-22). Items drawn using
computer technology can be edited, saved, copied,
resized, colored, and manipulated in a range of ways.
Templates for areas around the home can be created that can be easily modified through the use of
drawing tools to add more detail to the illustration.
For example, therapists might create templates of
bathroom or toilet areas for quick and easy retrieval
to add in illustrations of grab rails. Further, photos,
cut-outs, photocopies, and other documents can
be uploaded and manipulated using software tools.
Software packages provide a variety of tools, including pens, airbrushes, drafting tools, and texture
maps (Montague, 2005).
Drawings developed using CAD programs or
specific software for use by health professionals
appear professional and stylish and make it easier
to achieve accuracy of scale (see Figure 8-22).
These programs have additional desirable features,
including the ability to draw to scale and to import
symbols that adapt to the scale. Further, some CAD
programs allow scaled drawings to be converted to
two- and three-dimension images with walk-through
views. However, to be able to make full use of such
computer software, therapists require training. The
more sophisticated the program, the more features
and drawing options provided, and the greater the
level of skill and expertise required to operate them.
Experienced draftspeople and architects are the
main users of this technology, although industry
training and packages are available that range from
simple to complex that can be used by occupational therapists. Further, these packages usually
contain training tutorials. It is often assumed that
CAD-based drawings have been developed for use
by people with building and design knowledge and
expertise. Bearing this in mind, therapists who use
CAD to develop concept drawings should state that
they are to provide an overview of the area only and
do not provide the specific technical detail required
for building works. They should be careful to clarify
that they do not have professional knowledge and
expertise in design and construction.
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Chapter 8
Figure 8-22. Occupational therapist’s drawings of the bathroom using (A) Word, (B) CAD, (C) OT Draw, (D) (i, ii, iii, iv, v)
Idapt Planning (Reprinted with permission from Idapt LLP,
Acton Turville, UK); and (E) photos of bathroom features after
modification (continued).
B
A
C
Drawing the Built Environment
D-i
D-ii
D-iii
D-iv
D-v
193
E
Figure 8-22 (continued). Occupational therapist’s drawings of the bathroom using (A) Word, (B) CAD, (C) OT Draw, (D) (i, ii, iii,
iv, v) Idapt Planning (Reprinted with permission from Idapt LLP, Acton Turville, UK); and (E) photos of bathroom features after
modification.
194
Chapter 8
CONCLUSION
REFERENCES
This chapter discussed how a client’s home modification requirements can be represented in concept
drawings that complement photos and other information that has been put in writing in the occupational therapy report. Though occupational therapy
concept drawings are not architectural drawings,
they can become the basis for the development of
more detailed technical drawings by design or construction professionals. This chapter has described
the resources to guide occupational therapy drawing
practice, the basic requirements for drawings, and
tools and technology that can provide further information to guide knowledge and skill development in
the area.
This chapter has not sought to provide comprehensive information to ensure occupational therapists are competent in drawing. Rather, it has reinforced the need for therapists to consider training
in the area to ensure that home visit documentation
that is produced is clear and concise and communicates information that is easily understood
by people working in the design and construction
industry. This chapter has discussed how occupational therapists should take advantage of industry
training courses and review available hard-copy and
online resources in the field to become familiar with
design and construction industry requirements and
to ensure good communication with those completing the home modification work.
American National Standards Institute. (2009). ICC/ANSI A117.12009: Accessible and usable buildings and facilities. New York,
NY: Author.
Ashlee, P., Clutton, S., Pengelly, S., & Cowderoy, J. (2006).
Conveying information through drawing. In S. Clutton, J.
Grisbrooke, & S. Pengelly (Eds.), Occupational therapy in housing: Building on firm foundations (pp. 83-108). London: Whurr
Publishers.
Bielefeld, B., & Skiba, I. (2013). Basics: Fundamentals of presentation. Technical drawing. Boston, MA: Birkhauser.
Ching, F. D. K. (2015). Architectural graphics. Hoboken, NJ: John
Wiley and Sons.
Ching, F. D. K., & Eckler, J. F. (2013). Introduction to architecture.
Hoboken, NJ: John Wiley & Sons.
Clutton, S., Grisbrooke, J., & Pengelly, S. (2006). Occupational
therapy in housing: Building on firm foundations. London:
Whurr Publishers.
Dernie, D. (2014). Architectural drawing (2nd ed.). London:
Lawrence King Publishing Ltd.
Housing Industry Association & Illaring Pty Ltd. (2006).
Introduction to drafting: Participant guide. Brisbane, Australia:
Author.
International Organization for Standardization. (1979).
International Standard ISO 5455. West Conshohocken, PA:
ASTM International.
Montague, J. (2005). Basic perspective drawing: A visual approach.
Hoboken, NJ: John Wiley & Sons.
Standen, D. (1995). Construction industry specifications. Victoria,
Australia: The Royal Australian Institute of Architects.
Thorpe, S. (1994). Reading and using plans. London: Center for
Accessible Environments.
Wang, T. C. (1996). Plan and section drawing. Hoboken, NJ: John
Wiley & Sons.
Weidhaas, E. R. (2002). Reading architectural plans for residential
and commercial construction (5th ed). Upper Saddle River, NJ:
Prentice Hall.
Yee, R. (2012). Architectural drawing: A visual compendium of types
and methods (4th ed). New York: John Wiley & Sons.
Developing and
Tailoring Interventions
9
Desleigh de Jonge, MPhil (OccThy), Grad Cert Soc Sci;
Melanie Hoyle, BSc (Psych), MOccThySt, Grad Dip Health Sci, Post Grad Dip Psych;
and Elizabeth Ainsworth, MOccThy, Grad Cert Health Sci
Occupational therapists address a variety of occupational performance issues in the home using a
range of interventions. Based on an analysis of the
person-environment-occupation transaction and the
home environment, occupational therapists identify alternative strategies, assistive devices, social
supports, and modifications to the environment to
promote occupational performance. In developing
an intervention strategy, the occupational therapist
collaborates with the client to find the solution that
best fits with the person and the way he or she
engages in occupations in the home environment.
This chapter will outline the various approaches
occupational therapists use to enhance occupational
performance in the home and provide a structure
for analyzing the suitability of various interventions.
The role of clinical reasoning in determining the
most suitable intervention will also be discussed.
In addition, the chapter will introduce occupational
therapists to architectural elements of the built environment that might be considered when tailoring
interventions to suit the person-environment fit and
will present a framework for developing and tailoring
environmental interventions.
CHAPTER OBJECTIVES
By the end of this chapter, the reader will be able
to:
Ô Describe the typical occupational performance
issues faced by people in the home
- 195 -
Ô Describe the range of interventions that occupational therapists use to enhance occupational performance in the home
Ô Describe a systematic approach to identifying
potential interventions
Ô Discuss the potential interaction between interventions and the person, the nature of the
occupation, and the environment
Ô Discuss the use of clinical reasoning in determining the most suitable intervention option
Ô Describe the use of architectural elements in
developing environmental interventions
Ainsworth, E., & de Jonge, D. An Occupational Therapist’s
Guide to Home Modification Practice, Second Edition (pp. 195-223).
© 2019 SLACK Incorporated.
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Chapter 9
Box 9-1. Problems Reported by Older People
in the Home
• External access: Walking on uneven pavements,
dealing with slopes, steps, clutter, and ground
surfaces
• Entry: Getting in/out of the house, managing stairs,
locks, keys, and doorknobs
• Internal mobility: Mobilizing inside the house,
negotiating stairs, clutter, obstacles, level changes,
slippery surfaces
• Interior (general): Poor lighting, managing control and
outlets, hearing doorbell, and using telephone
• Living room: Getting up from chairs
• Bathroom: Getting into and out of tub, completion of
bathing and showering, dressing from waist down,
transferring to toilet (toilet too low), completion of
toileting, difficulty with faucets
• Kitchen: Cabinets too high, too low, difficulty using
appliances, trash disposal
• Bedroom: Getting in and out of bed
Adapted from Connell & Sanford, 1997; Gitlin et al., 2001, 2006;
Johansson et al., 2007, 2009; and Mann et al., 1994.
IDENTIFYING OCCUPATIONAL
CHALLENGES IN THE HOME
Occupational therapists commonly address
occupational challenges that result from a poor
fit between the person’s capacities, what he or
she needs or wants to do, and the demands of the
environment where the performance takes place.
Occupational challenges can arise as a consequence
of the following:
Ô Changes in a person’s functional capacities as a
result of aging, injury, impairment, or a health
condition
Ô Variations in occupational demands or the way
activities are undertaken
Ô Barriers or challenges presented by the
environment
When evaluating occupational performance of
various valued and required activities in and around
the home, occupational therapists analyze the person-environment-occupation transaction to identify
a specific cause for any difficulties experienced and
determine how occupational performance can be
further enabled. From this analysis, occupational
therapists are able to develop a number of alternative intervention options to address the identified
concern and to further enhance performance.
Traditionally, occupational therapists have
focused on the impact of various impairments and
functional deficits on daily activities and sought to
maintain or enhance health, safety, and independence by recommending assistive devices or alternative methods of undertaking activities. Increasing
focus is now being given to the environment and
the demands it places on people. Conventional
housing design creates a number of challenges for
older people and people with disabilities as they
go about their daily activities. Houses with stairs,
narrow doorways and corridors, inaccessible toilets
and bathrooms, and limited space “create” disability
(Heywood, 2004a; Oldman & Beresford, 2000) and
can compromise a person’s health, safety (Stone,
1998; Trickey, Maltais, Gosslein, & Robitaille, 1993),
independence (Frain & Carr, 1996), and well-being
(Heywood, 2004a). Studies undertaken by Connell
and Sanford (1997); Gitlin, Hauck, Winter, Dennis,
and Schulz (2006); Gitlin, Mann, Tomita, and Marcus
(2001); Johansson, Josephsson, and Lilja (2009);
Johansson, Lilja, Petersson, and Borell (2007); Mann,
Hurren, Tomita, Bengali, and Steinfeld (1994); and
other authors have identified a number of problems
experienced by older people in the home environment that would be equally relevant for people with
various impairments and health conditions (Box
9-1).
The design of the residence can:
Ô Place people at risk of incidents or accidents
resulting in injury
Ô Make it difficult for people to carry out daily
activities in and around the home
Ô Place unnecessary demands on people in terms
of managing and maintaining the environment
People need to feel well supported by their home
environment. When the home provides too many
challenges, it can place people at risk of injury arising from incidents or accidents. A challenging home
environment can undermine confidence and make
people apprehensive and even fearful as they go
about routine activities in the home and community.
Poorly designed environments may also affect relationships (Heywood, 2004a, 2005; Tanner, Tilse, &
de Jonge, 2008), interactions with family and cohabitants (Granbom, Taei, & Ekstam, 2017; Heywood,
2004b), and the capacity of people to get out of the
home to participate in community activities (Bedell,
Khetani, Cousins, Coster, & Law, 2011; Gillespie et
al., 2009; Heywood, 2004b; Law, Di Rezze, & Bradley,
2010; Pettersson, Löfqvist, & Malmgren Fänge, 2012).
Developing and Tailoring Interventions
People need to be able to manage their home environment—open windows, operate controls, answer
the telephone and doorbell (Connell & Sanford,
1997), and maintain the home in order to feel comfortable and safe. Older people and people with disabilities often experience difficulties cleaning and
maintaining their homes (Peace & Holland, 2001).
Homes that are unkempt and poorly maintained
can create further hazards and can expose the
occupants to increased risk of home invasions when
passers-by realize that residents may be vulnerable
and may not be able to defend themselves (Jones, de
Jonge, & Phillips, 2008).
INTERVENTIONS USED TO
ADDRESS OCCUPATIONAL
PERFORMANCE ISSUES
In the home environment, occupational therapists
aim to assist people to find ways to perform routine
activities of daily living and household tasks that,
however inconsequential they might seem, can be
integral to leading a full and satisfying life (Crepeau,
Schell, Gillen, & Scaffa, 2014). Interventions can
address a presenting problem by establishing or
restoring the person’s capacities, altering the way
the task is undertaken, or adapting or modifying the
existing environment (Dunn, Brown, & McGuigan,
1994). Alternatively, the person-environment-occupation fit can be altered (Dunn et al., 1994; Iwarsson
et al., 2016; Wahl, Fänge, Oswald, Gitlin, & Iwarsson,
2009) by moving the person to a more supportive
environment or providing additional support in the
way of informal or formal assistance. In some cases,
occupational therapists support other people in caring for or assisting people with severe or degenerative conditions (Rogers & Holm, 2009). This type of
intervention is referred to as a palliative intervention
(Rogers & Holm, 2009). Occupational performance
difficulties can also be prevented by anticipating
potential problems before they occur (Dunn et al.,
1994). Furthermore, occupational performance can
be enriched by creating enabling environments
that promote activity engagement and well-being
(Dunn et al., 1994). When providing interventions in
the home, occupational therapists need to not only
address identified problems, but also be mindful of
preventing future problems and creating environments that enrich occupational performance and the
experience of home.
Interventions can be focused on the person,
task, or environment (Rogers & Holm, 2009).
197
Person-oriented interventions attempt to remediate
the person’s capacity or manage his or her performance difficulties when undertaking activities by:
Ô Maintaining or restoring functions such as
muscle strength, endurance, attention, concentration, and visual scanning
Ô Managing issues such as reduced vision, pain,
fatigue, and short-term memory difficulties
Ô Establishing habits and routines for activities
that need to be undertaken regularly
These interventions usually require education,
training, and, in some cases, regular involvement with
an occupational therapist. Consequently, they are
mostly recommended for clients who can modify their
usual approach to tasks, follow a prescribed program
independently, or regularly access a rehabilitation program. In contrast, environment-focused interventions,
such as home modifications, recognize the person’s
existing capacities and seek to optimize occupational
performance by eliminating barriers in the home and
creating a more supportive environment.
CONCEPTUAL FRAMEWORK FOR
DEVELOPING INTERVENTIONS
Everyday activities are commonly undertaken
using a combination of strategies, tools, and social
and physical supports in the environment (Dunn
et al., 1994; Enders & Leech, 1996). Each individual
uses a unique blend of these resources to carry out
activities in a preferred way. Changes in the person’s capacities, the demands of the activity, or the
resources available usually prompt people to modify
their approach to the task (the strategy), the tools
they use, or the way they use the social and physical
elements in the environment. For example, there is
substantial variation in the way people undertake a
simple activity such as cooking scrambled eggs:
Ô First, the activity is guided by the preferred
outcome; that is, whether the individual prefers
eggs light and fluffy, creamy, firm, with a natural flavor, lightly salted, spicy, etc.
Ô How the task is undertaken is governed by the
person’s cooking skills, experience, and knowledge and how he or she was shown to scramble
eggs.
Ô The nature of tools available, such as whisk,
pans, microwave, and cook-top, dictates how
the tasks will be performed.
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Chapter 9
Figure 9-2. Framework for developing interventions.
Figure 9-1. Generic support system for human accomplishment. (Reprinted with permission from Albrecht, G. L., Seelman,
K. D., & Bury, M. [2001]. Handbook of disability studies. Thousand
Oaks, CA: Sage Publications.)
Ô Finally, the people available to help and the
space and layout of the kitchen will shape the
way the necessary tasks are undertaken.
If the person is cooking for a number of guests
with varying preferences, has an injured hand,
breaks the whisk, is offered assistance, or is cooking
in a different kitchen, he or she will need to alter the
strategy, reconsider the tools, or structure the social
and physical environment differently.
Litvak and Enders (2001) described a generic support system for human accomplishment as including
strategies, tools, and cooperation and described
the function of people with disabilities as being
variously supported by adaptive strategies, assistive
devices (tools), and personal assistance or social
support (Figure 9-1).
This is a useful framework for thinking about
ways in which occupational performance can be
supported when people encounter difficulties. As
highlighted in the ecological models, such as PersonEnvironment-Occupation-Performance (Baum &
Christiansen, 2005; Baum, Christiansen, & Bass,
2015; Christiansen & Baum, 1997) and the PersonEnvironment-Occupation (Law et al., 1996), discussed in Chapter 3, occupational performance is a
function of the dynamic and reciprocal interaction
between the person, occupation, and environment.
Therapists seek to optimize occupational performance by improving the fit between the person
and his or her occupations and roles and pertinent
environments. Working with the unique capacities,
skills, preferences, and experiences of each individual, therapists examine how strategies, tools,
and the social and physical environment are currently working to support occupational performance
and how they might be modified to optimize that
performance.
To illustrate the relationship between the personenvironment-occupation transaction and these supports, Litvak and Ender’s (2001) model of support
systems has been modified and superimposed on
the Venn diagram of the person-environment-occupation interaction (Figure 9-2).
The curved/Reuleaux triangle created by the intersection of the person, occupation, and environment
represents occupational performance. Each side of
this triangle represents the resources that support
occupational performance—namely, strategies (the
way the person approaches the occupation), tools
(the devices in the environment used to support the
occupation), and the social and physical environmental supports (the resources the person avails
him- or herself of in the environment). This simple
graphic representation provides therapists with a
mechanism for examining and acknowledging the
current supports available and exploring alternative
ways of supporting and enhancing occupational performance. It also recognizes the role of occupational
analysis in evaluating the person-environment-occupation transaction and the contribution of strategies, tools, and social and physical environmental
supports to occupational performance.
Developing and Tailoring Interventions
199
Strategies or Adaptive Approaches
to Enhance Occupational
Performance
supports such as tools or environmental interventions such as home modifications, which can promote a change in approach and decrease reliance on
unsafe methods.
Occupational therapists have a long tradition of
making activities more manageable by altering the
way they are undertaken. Activities can be done a
different way using energy conservation or work
simplification techniques to reduce the physical
demands on the person. People can sit to undertake parts of a task or take regular rest breaks to
conserve energy. Rescheduling activities to another
time when the person is more energetic and mobile
(e.g., in the morning) can also enhance performance.
Activities can also be scheduled at specific time
intervals to remove the complexity or urgency of
performance (e.g., establishing regular times for
toileting to reduce accidents and the need to rush
to the toilet). Sometimes, activities can be simplified
and broken into a number of tasks to reduce the cognitive load. They can also be reordered or relocated
to make them easier to perform. For example, during bathing, it might be easier to sit in the bedroom
when undressing and dressing rather than attempting this task while standing in what might be the
cluttered and slippery environment of the bathroom.
People often develop their own alternative strategies to address difficulties in occupational performance. For example, when getting up from a low
toilet, many people grab hold of fixtures and fittings
in the room such as the toilet roll holder, towel rail,
or door handle to assist. Though it is important to
acknowledge people’s resourcefulness in solving
everyday problems, some of these strategies are
not safe, practical, or sustainable and can place the
person at risk of injury. Occupational therapists
might suggest a range of alternative strategies to
keep the person safe during such a transfer, such
as placing hands on knees to assist with lift-off or
“keeping nose over toes” to maintain the center of
gravity over the base of support (Chan, Laporte, &
Sveistrup, 1999; Deane, Ellis-Hill, Dekker, Davies, &
Clarke, 2003). However, it is often difficult to change
entrenched patterns of behavior. Many occupations
in the home are undertaken using individual and
unique approaches that have been honed over many
years and have become habitual and almost instinctive. Because people are often unable or unwilling
to change the way they undertake tasks, therapists
need to work closely with them to find alternative methods that are comfortable and acceptable.
Alternatively, therapists can explore the use of other
Tools or Assistive Devices
to Enhance Occupational
Performance
Tools or assistive devices are another intervention strategy used by occupational therapists to
address occupational performance issues in the
home. This intervention strategy is often easiest
for therapists to use because myriad devices are
available to address a variety of performance and
troublesome task components. Information on specialized devices is readily available through catalogues and equipment databases. For a number of
health conditions, assistive devices are viewed as
a routine element in treatment protocols. Assistive
devices are frequently funded through a range of
schemes because they are generally more affordable and more readily available than environmental
interventions. However, assistive devices can often
change the way tasks are undertaken and, in some
cases, can increase the complexity of the task. For
example, tub transfer benches and shower chairs
require people to sit to shower. This changes the
nature of the task, possibly removing the relaxation
experienced when standing under a showerhead and
having warm water spraying down the back. Sitting
to shower may create difficulties in washing the
perineal area. Tub transfer benches are frequently
removed because they get in the way of others who
use the bathroom. The task of then replacing the
bench and fitting it safely can often prove challenging for the user.
Assistive devices are not always easy to use. For
example, it might be easier for some people to walk
through the house leaning on the walls for support
rather than to navigate a wheeled walker through
narrow hallways and doorways. Useful devices are
not always at hand when needed. Reachers are very
useful for retrieving items out of reach; however,
they need to be nearby when required. This means
keeping a reacher in each room of the house or carrying it around in case it is needed. With abandonment of assistive devices a major concern (Batavia &
Hammer, 1990; Hocking, 1999; Mann & Tomita, 1998;
Phillips, 1993; Scherer, 2005), it is evident that many
people are receiving devices they do not need or are
unable or unwilling to use long term.
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Chapter 9
Social Supports to Enhance
Occupational Performance
People with significant physical, psychological,
social, sensory, or cognitive difficulties often receive
formal and informal personal assistance to help
them successfully complete activities. Support can
be provided in the form of organizational assistance,
verbal prompting, or physical support or assistance.
Assistance might be required prior to, during, or
after the activity is completed. For example, a family member could prepare the area for the activity,
supervise performance, verbally prompt the person
through the tasks, or physically assist the person
at various stages or throughout the entire activity.
Where he or she is no longer able to undertake the
activity, another family member or a paid caregiver/
service provider might assume complete responsibility for completing the task (e.g., doing the laundry
or mowing the lawn).
Therapists need to understand what informal
supports are available to assist the person and
determine whether caregivers are willing, or have
the capacity, to provide the required assistance. If
appropriate support is available, therapists need
to ensure that assistance is provided in a way that
maintains the person’s autonomy and safety and,
wherever possible, that the meaning of the occupation to the person is retained. For example, people
might bathe before bed to relax. When a caregiver
is assisting with this task, the focus often shifts to
cleaning the person as efficiently as possible rather
than providing a routine with activities focused on
comfort and relaxation. The activity can become
centered on the availability and needs of the caregiver rather than the needs of the person being
bathed. This is understandable, but when someone
is always dependent on others for assistance, the
loss of control over daily routine and the relaxing
pre-bed routine (or the routine of that whole day)
can be distressing and might even have implications
for the person’s long-term health and well-being.
Therapists are also concerned with the health
and well-being of caregivers, especially when they
are providing support over an extended period. This
is a particularly important consideration as it has
been identified that a significant portion of primary
carers have a health condition/disability themselves
(Australian Bureau of Statistics, 2013). The occupation of caring can also become a focus of intervention, with alternative strategies, assistive devices,
and environmental modifications used to minimize
the demands on the caregiver and reduce the risk of
injury (Aplin, de Jonge, & Gustafsson, 2015; Heaton
& Bamford, 2001; Heywood, 2004a; Stark, Keglovits,
Arbesman, & Lieberman, 2017).
Formal caregiver assistance can also be used to
support the completion of a range of activities; however, the amount and type of assistance available
can vary from one location to another. Therapists
need to be aware of the resources available within the local community and use these effectively.
Formal assistance removes the demands on the family and frees the client from being dependent on family members for his or her daily needs. When clients
receive assistance with routine tasks, such as bathing, it allows them to invest their limited time and
energies in more highly valued occupations, such as
parenting or work.
However, these formal caregiver services can be
costly and often determine when and how activities are completed. Caregivers can also intrude
on personal spaces and disrupt personal routines.
Formal support can disrupt social relationships and
routines in the household and extended family. For
example, a client once declined the offer of a formal
service to do the weekly washing of her bed linen
and larger items. The client was able to manage
washing her smaller items but had her daughter
wash the bed linen when she visited each week. She
was concerned that if she removed the daughter’s
reason for visiting, she may not visit as regularly
or might cease to visit at all. This task provided an
opportunity for the client to prepare a snack for her
daughter while she stripped the bed and put the
linen in the washing machine. She could then watch
television with her while they waited for the washing
to dry. Further, it allowed the daughter to do something concrete and meaningful for her mother. The
mother-daughter relationship required the structure
of these activities because the client appeared to be
a very practical and matter-of-fact woman who did
not engage easily in general social chatter.
Environmental Supports
to Enhance Occupational
Performance
Occupational performance can also be enhanced
by modifying the environment. Spaces can be reallocated, expanded, rearranged, remodeled, or redesigned to allow the client to perform activities more
effectively. In addition, fixtures and fittings can be
removed, relocated, replaced, or added to enhance
performance. Sometimes, a room on the first floor—
a study, for example—can be reassigned as a bedroom so that the client does not have to climb the
stairs to go to bed. Further, a separate and adjacent
Developing and Tailoring Interventions
toilet and bathroom may be combined by removing
the dividing wall to allow greater circulation space
for both activities. The orientation or position of
furniture or fixtures and fittings can also be changed
to facilitate access and performance in the room. For
example, vanity units may be relocated, baths may
be removed, and the inward swing of the door into
the toilet may be reversed to increase circulation
space.
Home modifications can include repairs, maintenance, nonstructural or structural modifications,
and the integration of smart technologies. Generally,
nonstructural modifications are referred to as
minor modifications and structural modifications
are termed major modifications. For a review of the
differences between minor and major modifications
and an in-depth discussion of modification complexity and associations with situational complexity, see
Chapter 5. Repairs and maintenance are essential to
ensuring the ongoing integrity of the environment
and the safety and well-being of the occupants.
Common repairs and maintenance tasks include the
following:
Ô Mending stairs, handrails, paths, and flooring
Ô Removing clutter and trip hazards
Ô Installing and/or replacing lighting, locks, security screens, smoke alarms and carbon monoxide detectors, and faucets
Minor modifications may involve installing items
that incorporate nonstructural changes to the home
and include the following:
Ô Installing grab bars, rails, shower hoses, door
wedges, stair climbers, and privacy screens
Ô Fitting shower seats into shower recesses
Ô Altering door swings and window openings
Ô Replacing faucets and door handles
Ô Installing slip-resistant adhesive strips in baths
and showers and on stairs
Ô Installing slip-resistant flooring
Ô Inserting solid risers between open treads
Ô Repainting walls, door frames, and stair edges
Ô Repositioning fixtures and fittings
Ô Introducing specialized shelving, drawers,
and hanging rails into storage cupboards and
closets
Ô Adding and/or relocating controls, light fittings,
and power and telephone outlets
Major modifications are structural changes to the
home that incorporate changes to the fabric of the
dwelling and include the following:
201
Ô Widening doorways and passages
Ô Moving or removing walls and combining
spaces
Ô Redesigning bedrooms, laundries, bathrooms,
toilets, and kitchens
Ô Installing ramps, pathways, roll-in shower
recesses, and elevators
Ô Replacing toilets with accessible pans and
cisterns
Ô Removing shelving and cupboards under sinks
and hotplates
Ô Installing additional height-adjustable pantries
and shelving
Ô Lowering countertops, cupboards, and windows
Ô Raising flowerbeds
Ô Adding or reassigning rooms
Increasingly, smart technologies are being used
to help people maintain their health and well-being,
supporting them to remain living safely and independently in their own homes. These technologies may
or may not require structural work or changes to the
home’s plumbing and electrical systems. Security
and home automation systems provide older people
and people with disabilities with improved safety
and security and an efficient means of managing
their home environment. Environmental and remote
control systems and devices allow people to manage their environment and the fixture and fittings
within it (e.g., automatic door openers, keyless entry,
remote window and curtain opening, automated
lighting sensors, etc.). Mobile phones can also be
used to regulate the temperature, lighting, electrical outlets, air conditioning, and security of homes
and to answer and open front doors through connection with intercoms. A growing number of home
entertainment options, including smart televisions,
accessible/online computing and gaming systems,
etc. afford people many different ways of enjoying
their time at home. Mobile phones, video chat, and
telepresence allow people to maintain contact with
friends and relatives. Alarms, automated detectors
(e.g., falls and seizure), and emergency call devices/
systems ensure that people are able to access assistance as required. Those who need to monitor the
whereabouts or safety of a loved one at home can
use technologies such as remote cameras, sensors,
and wearable devices to oversee or monitor movement and activity remotely. Various devices, sensors,
administration aids, and apps also assist people and
their health care teams to manage complex health
conditions, monitor vital signs, identify changes in
performance and/or behavior, or record or predict
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an adverse event within the home. A range of highand low-technology assistive devices enable people
to undertake their daily activities with greater ease
by facilitating movement, reducing the impact of
conditions/symptoms, enabling participation, augmenting the senses, and/or supporting caregivers to
assist in the completion of activities. Reminder and
scheduling technologies can also be used to assist
people to manage their routines by prompting them
through various tasks such as their self-care routine
in the bathroom, cooking, and collecting the mail.
Modifications to the environment can make it easier and safer for people to engage in valued occupations and to participate actively in family and community life. They can remove the burden of using an
unfamiliar strategy and specialized devices or relying on others to be available for support. However,
on the negative side, they can be disruptive and
change the way the home is used by other household
members and visitors. They may also change the
look and feel of spaces in the home, the associated
memories, and the personal identity derived from
the design and décor (Aplin, 2013; Aplin et al., 2015).
Modifications can also be costly. People mostly rely
on social services or their own personal resources
to fund modifications, so therapists need to be familiar with the building and funding resources available
within the community to access environmental interventions effectively (Rigby, Trentham, & Letts, 2014).
DEVELOPING INTERVENTION
STRATEGIES
Identifying a range of suitable interventions to
address occupational performance difficulties is
a complex task. Each person has unique capabilities, expectations, preferences, and experiences and
has a distinctive way of undertaking activities. In
addition, as outlined in Chapter 1, the home environment, including the physical, personal, social,
temporal, occupational, and societal dimensions,
needs to be considered when proposing and developing any type of intervention (Aplin, de Jonge, &
Gustafsson, 2013). Therapists traditionally use occupational analysis, professional reasoning, and problem solving in developing their understanding of
occupational performance difficulties and the range
of possible interventions. Additionally, they tailor
interventions to suit each situation, drawing on their
knowledge of strategies, assistive devices, products,
and design, as well as their professional experience.
USE
OF
OCCUPATIONAL ANALYSIS
Therapists use occupational analysis to develop
a clear and detailed understanding of the occupation and the specific way it is performed; to identify
where task breakdowns occur; and to analyze factors
that contribute to the breakdown. They then generate a list of alternative strategies, assistive devices,
social support, and modification options that have
the potential to address the identified occupational
performance difficulty. Building on the example of
going to the toilet discussed earlier in this chapter
and in Chapter 6, Table 9-1 details a range of alternative interventions for breakdowns at each stage of
the activity. Note that this is a theoretical analysis
and, as such, does not claim to be comprehensive or
account for the variation that may occur in the way
the activity is undertaken by an individual or the
unique characteristics of a home environment.
When analyzing activities, therapists are encouraged to consider the whole activity within the context of the relevant area of the home (i.e., access
to and egress from the activity area and all the
stages or elements of the activity from start to finish). Occupational therapists sometimes restrict
analysis to select parts of the activity, for example,
focusing exclusively on the transfer on and off the
toilet. Problems can arise when designing a support,
such as a grab bar, to assist with only one stage of
the activity. For instance, the therapist is likely to
overlook the impact of this support when the person
is attending to personal hygiene while seated on the
toilet. The grab bar might not provide the person
with the support he or she requires when shifting his
or her weight while seated and, more importantly,
could be an obstruction to the person when performing this action.
The type of intervention used is, in part, dependent
on the nature of the identified problem. Experienced
occupational therapists can often generate a number
of alternative solutions for any one difficulty. This
provides the client with the opportunity to select
the interventions that best fit his or her style and
preferences, the way he or she completes the activity, and the demands of the environment. Therapists
with limited knowledge of alternative options can
have difficulty problem solving unique situations
and responding to the specific requirements of the
individual and household. Because occupational
therapists have traditionally used alternative strategies or assistive devices to address occupational
performance issues, they are less familiar with the
range of ways the environment can be modified to
support performance.
Developing and Tailoring Interventions
203
Table 9-1. Interventions to Address Breakdowns in Going to the Toilet
TASK
STRATEGY
ASSISTIVE DEVICE
ENVIRONMENTAL
MODIFICATION
Register need to go to the
toilet
Set at regular intervals
Use an alarm to remind or
register moisture
Have a clock visible with
marker
Locate and find way to toilet Feel way along the wall
Install sensor lights
Use lighting or colored line
to illuminate way
Open the door
Leave the door open
Install sensor opener
Install lever handle or
reverse opening
Enter the room
Leave mobility device
outside of toilet
Place threshold ramp at
doorway
Widen doorway
Turn lights on and off at
night
Leave light on permanently
Install sensor light or timer
on light (i.e., turns off at
same time each night)
Large switch
Close the door
Leave the door open
Travel, turn, and position at
front of pedestal
Use cues or markers on the
floor
Remove level change
Install self-closing hinge
Use walking frame
Increase circulation space
Wear pants with elastic
waist
Hold onto grab bar
Use supportive lowering
technique
Use raised toilet frame
Raise pedestal
Reach for toilet paper/
release sheet
Use pretorn sheets
Use extend-a-hand
Transfer weight for wiping
Stand to wipe
Undress
Sit down onto toilet
Attend to personal hygiene
Install grab bar
Install automatic sheet
dispenser
Lean onto grab bar
Use toilet duck or other
wiping aid
Bidet
Move from sitting to
standing
Push up on knees
Use toilet frame
Push up on grab bar
Don and adjust clothing
Pull up to thighs while
seated
Use easy reacher
Hold onto grab bar
Turn and flush toilet
Leave unflushed
Modify button/lever
Auto flush
Clean toilet bowl
Brush with extended handle
Open door
Leave door open
Install sensor opener
Install lever handle or
reverse opening
Negotiate doorway
Leave mobility device
outside of toilet
Place threshold ramp at
doorway
Widen doorway
Feel way along the wall
Install sensor lights
Use lighting or colored line
to illuminate way
Use faucet turner
Level handles
Find way to sink to wash
hands
Turn on faucets
Wash hands
Use moist wipes/antiseptic
hand wash
Dry hands
Please note potential for
collapse or assistance need
Remove level change
Use electric hand dryer
Education for independent
getting up the floor
Emergency call system
Widen circulation space
and doorway to enable
assistance/attention
Lift off hinges
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Chapter 9
USE
OF
REASONING
The nature of the intervention chosen is dependent on a range of factors. First, the person is likely
to have specific skills and abilities, past experiences,
and preferences that influence how receptive he or
she is to an intervention. Second, although some
tasks are more conducive to a change in strategy,
others are better supported by an assistive device,
social support, or home modification. Third, other
people within or external to the home environment
are likely to influence decisions when interventions
affect how they perceive and/or use the home environment. Finally, the home environment might also
constrain what can be achieved as a result of the
design and physical structure of the house, including
building materials.
Therapists rely on professional reasoning to
determine the potential effectiveness and impact of
proposed interventions by using a combination of
scientific, narrative, pragmatic, ethical, and interactive reasoning to design acceptable, effective, and
workable home modifications. Refer to Chapter 6 for
a definition of each of these reasoning styles and the
contribution each makes to the evaluation process.
A description of the role reasoning styles play in
developing interventions follows.
Occupational therapists use scientific reasoning
to identify a range of suitable interventions and
tailor them to each client’s specific requirements.
Knowledge of interventions and their effectiveness—
derived from databases, professional literature, education and training events, and professional experience—guides therapists in selecting suitable options.
Therapists also review research to ascertain the
level of support for proposed interventions and the
applicability of this information to each client’s situation (Chapter 10 has further information on the use
of evidence in designing interventions). In addition,
therapists are able to design individualized solutions
using their expertise in anthropometrics, biomechanics, and ergonomics; knowledge of health conditions, impairments, and aging, including associated
impacts; and an understanding of occupational performance and various aspects of the environment.
Working within a person-environment-occupation theoretical framework, therapists examine the
potential impact of each option on the associated
interaction. For each alternative strategy, assistive
device, social support, or environmental intervention, the therapist asks the following questions:
Ô Person
É Can the client manage the alternative strategy, device, or approach to the occupation?
É Is he or she willing or able to do the activity
in a different way?
É Is he or she satisfied with the recommended
changes?
Ô Occupation
É How will the recommended option affect the
nature of the occupation?
É Is the recommended option well suited to
the unique way the person undertakes the
occupation?
É In what way does the recommended option
alter the occupation procedure, meaning, or
routine?
Ô Environment
É How well will the environment support the
recommended option?
É Are resources available in the environment
to support the recommended option?
É How does the recommended option affect
other people in the environment?
É How does the recommended option affect
the physical, personal, social, temporal,
occupational, and societal dimensions of the
home?
Therapists use narrative reasoning to explore
each client’s story, particularly their preferences
and perceptions of the effectiveness of the recommended options in addressing the identified problem and the potential impact of each solution on
the identified goal, the meaning of the occupation,
and the various dimensions of the home environment. It is essential that therapists also discuss the
proposed interventions with all household members to fully explore the impact of these on the
household.
Therapists use pragmatic reasoning to examine
the relative costs and availability of resources to
implement each option. The physical design and
materials of the house and immediate environment
can often define the suitability of interventions, particularly modifications. The focus and policies of services can also affect what, and how, resources are
made available. However, because clients retain the
right to decline the options on offer, they can also
access their own resources or an alternative service
to address their needs in their preferred way. It is
also important to remember that installation or construction might disrupt the household temporarily
and that the potential impact of these disturbances
on the household needs to be considered when
deciding on the most suitable option.
Developing and Tailoring Interventions
Therapists also use ethical reasoning to evaluate
the potential value of options and to identify the
most suitable solution for each situation. Although
therapists have a duty of care to deliver the best
possible intervention, they frequently use ethical
reasoning when working with inadequate resources
to determine how to proficiently implement an
effective solution. When clients and therapists differ in their understanding of the effectiveness and
impact of various solutions, therapists seek to fully
understand the person’s perceptions of each option
and provide him or her with a deeper understanding of their professional perspective. An exchange
of information and understanding may result in the
establishment of a workable solution that meets the
person’s goals and preferences and addresses the
therapist’s concerns, or the development of a plan to
achieve an appropriate solution. Ultimately, clients
have the right to do what they think is best in their
own homes, but therapists also have a responsibility to inform them of the potential risks in choosing
a less-than-ideal option. See Chapter 12 for further
discussion of managing ethical decisions.
Throughout the development of intervention strategies, it is vital that the occupational therapist and
client work in collaboration and that the therapeutic
relationship remains strong and intact to enable the
continuation of the necessary working alliance. To
this end, interactive reasoning is used by the therapist in order to consider the client’s preferences
and implement particular automatic and conscious
communication skills and interpersonal behaviors
that engage and motivate the client. This allows the
therapist to maintain a continued allied relationship
based in trust. This relationship is essential for gaining the information necessary for the other reasoning types to occur successfully and for the client to
have confidence in the value and intention of the
therapist’s intervention recommendations.
DETERMINING AND NEGOTIATING
SUITABLE OPTIONS
There are usually any number of potentially useful
alternative solutions to occupational performance
problems in the home; however, there are several
issues that can affect decision making, including economic, architectural, and social barriers (Rigby et
al., 2014). Cost is often a consideration when designing environmental interventions. It is important to
work responsibly within a budget, but therapists
should also be mindful of the potential long-term
costs of interventions. For example, some assistive
205
devices, such as a tub transfer bench for the bath or
an over-toilet frame, initially cost less to install than
a shower recess or an accessible toilet with grab
bars. However, these interventions can prove to be
more costly in the long term if the client deteriorates
and cannot manage sit-to-stand transfers. In addition
to possible further costs associated with additional
strategies, tools, and/or modifications to meet the
new needs, the client may require additional supervision or assistance to complete the task, or he or
she could sustain an injury from being incapable of
using the assistive device safely. It is well recognized
in the occupational health and safety arena and in
the area of workplace accommodations that there
is a hierarchy of interventions that vary in terms of
anticipated effectiveness. It is proposed that environmental interventions are among the most effective in managing risk and reducing incidents and
accidents (Peek-Asa & Zwerling, 2003) as it can be
difficult for people to change entrenched behaviors
in familiar environments.
The design and structure of the home also pose a
number of challenges when designing environmental
interventions (Rigby et al., 2014). Therapists need to
understand the constraints presented by the built
environment in order to determine what is feasible.
Because this is not an occupational therapist’s area
of expertise, it is advisable to consult a design or
construction professional to provide technical building advice on the suitability of the home for modification. Further information will be provided later in
this chapter to assist therapists in understanding the
complexities they are likely to encounter when working with the built environment.
Although home visits provide therapists with an
enriched understanding of clients and their home
environment, therapists, in reality, experience only
a snapshot of people’s lives at the time of these
visits. It is therefore critical to examine solutions
thoroughly with clients to ensure that they will fit
well with them and their families, routines, lifestyles,
and home environments. Collaboration is required
if interventions are to be effectively designed to
suit the goals and preferences of clients and their
families.
The nature of interventions considered is also
likely to be influenced by factors related to therapists’ knowledge, experiences, models of practice,
and the service and information resources available.
Each therapist tends to have a particular scope of
knowledge and expertise, which will likely affect
the options identified. Therapists who have worked
with particular products or designs are likely to
favor these over less familiar options. The models of
practice therapists employ also predispose them to
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Chapter 9
using some interventions in preference to others. For
example, therapists using a rehabilitation framework
are likely to focus on remediating function before
compensating for lost function by using assistive
devices or removing barriers in the environment
to accommodate specific impairments and activity
limitations. On the other hand, therapists using a
Person-Environment-Occupation model would focus
primarily on enabling occupational performance by
ensuring that the environment was designed to promote engagement in personally meaningful activities
in the home and community.
Therapists might work within a particular service
with its own specific focus, policy, procedures, or
protocols that dictate the resources therapists have
readily available to them. Some services and agencies
fund assistive devices more readily than environmental interventions, which define the intervention
options available. The availability of technical advice
can also vary between services, which affects therapists’ capacity to consider modifications that require
structural changes or building expertise. Though
research and industry standards provide information
on the safety and effectiveness of some interventions,
there can be limited information on other options.
This can result in options such as exercise, education,
and assistive devices being favored in the absence of
evidence on environmental interventions. Further,
the detail provided in the access standards on the
design requirements of independent adult manual
wheelchair users often predominates because little
is known about the design requirements of people
with severe and multiple impairments who use other
devices and rely on caregiver support to complete
activities in areas of the home.
TAILORING INTERVENTIONS
Environmental interventions in the home need
to be practicable and acceptable to the client and
other household members and accommodate everyone who lives in or visits the home regularly. They
should not only address the identified problem but
should also promote occupational performance and
ensure that the essential qualities and meaning of
activities and the home environment are retained.
Therapists should also ensure that the interventions
will not cause any unexpected stress or discomfort
and will not create new issues for the person in the
home environment.
Therapists generally tailor the intervention to the
specific requirements of the person, the occupation,
and the environment, giving consideration to the
following:
Ô The characteristics of the person
Ô The way the activity is undertaken and, specifically, where performance breakdowns or difficulties occur and/or where the activity could
be further supported
Ô Whether the environment can accommodate
an intervention or places any constraints on its
availability, usefulness, or location
Characteristics of the Person
When tailoring an intervention for a specific
situation, therapists consider the person’s goals;
preferences; specific impairments and occupational
performance difficulties; ability to cope with the
intended change; and general skills, abilities, and
capacities that include the anthropometrics of the
person(s) likely to use the intervention. People have
preferred ways of approaching activities and also
personal experiences and likes/dislikes that can
affect their decisions. Some people find it difficult
to approach a task in a different way, so it is important that therapists acknowledge this and devise
therapeutic interventions that work with the client’s preferred approach. Other household members
using the space will also be affected by the changes
and will need to be consulted during the planning
process.
Therapists determine whether the individual has
specific impairments in his or her sensory, motor,
cognitive, or psychosocial function that may present
additional difficulties and ensure these are accommodated in the design of the solution. For example,
when recommending the installation of a grab bar to
assist during toileting, the therapist would consider
the following:
Ô Static balance in the seated and standing positions and dynamic balance when moving to
ascertain the amount and type of support
required
Ô Strength and coordination of the upper limbs
and condition of the joints and muscles to
determine whether the grab bar can be used
for pushing or pulling during sit-to-stand or
side-on transfers
Ô Sensation to establish whether additional slip
resistance is required
Ô Vision and visual perception to determine the
degree of color contrast required
Ô Cognition to establish whether the person
requires any training, prompting, supervision,
or assistance in using the grab bar
Developing and Tailoring Interventions
207
Figure 9-3. Phases of rising. (Reprinted
from Laporte, D. M., Chan, D., & Sveistrup, H.
[1999]. Rising from sitting in elderly people,
part 1: Implications of biomechanics and
physiology. British Journal of Occupational
Therapy, 62[1], 36-42.)
Ô The person’s confidence and self-efficacy during the activity
Anthropometrics, which uses standardized methods of measurement, can also assist therapists in
determining the most suitable configuration and
position for a grab bar. Chapter 7 provides a detailed
description of this methodology. Therapists often
use anthropometrics to tailor the intervention to suit
each client. They assess the person’s:
Ô Body weight to choose a rail that has been load
tested to manage the person’s weight (downward and sideward force)
Ô Location of key body landmarks and reach
range when seated and standing to determine
the required height of the bar above the floor
Ô Length of forearm to establish the preferred
length of the grab bar
Ô Hand size to guide the size of the diameter of
the grab bar
Ô Grip strength to guide the size of the diameter
of the grab bar and the finish on the surface of
the bar
Ô Right- or left-hand dominance to determine
the side of the toilet on which the bar should
be placed (influenced by the side of the body
affected by the person’s health condition or
disability, his or her presentation, and how he
or she completes activities)
Characteristics of the Activity and
Occupation
Therapists customize solutions to support clients
through troublesome aspects of activities while
ensuring that other aspects of the activity are not
disrupted. For example, when designing a grab bar
to assist an individual to transfer on and off the
toilet, the therapist observes the client’s posture,
movement, and center of gravity in relation to his
or her base of support and notes specific aspects
of the transfer that are problematic. With an understanding of the biomechanical factors that affect
the sit-to-stand transfer, the therapist determines
whether the client is experiencing difficulty with
flexion momentum, lift-off, extension, and stabilization (Laporte, Chan, & Sveistrup, 1999; Figure 9-3)
and recommends the grab bar configuration accordingly. If a client is having difficulty bending forward,
the therapist might provide a vertical grab bar that
he or she can pull on to move forward. If lift-off is
problematic, the therapist might provide a horizontal grab bar to push up on. To assist the client in the
extension or stabilization stage of the transfer, the
therapist might provide a diagonal or vertical bar
that the client can hold on to while transitioning into
standing and to arrest the movement to maintain a
static standing posture. If a client stands for toileting rather than sitting, a vertical grab bar may be
required to provide stability in this position. A vertical or diagonal grab bar may also assist as the client
moves from standing to sitting on the toilet, as these
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Chapter 9
configurations allow the hand to move down the rail.
It is important to note that if the client experiences
difficulty at each stage of the transfer, the grab bar
configuration would need to incorporate each of
these elements.
The therapist would also determine other aspects
of the activity where the client could benefit from
grab bar support and ensure that the solution
is adequate for these aspects of the activity. For
example, clients might require support when shifting
their weight while seated to attend to their hygiene
or when standing to adjust clothing. In addition, the
therapist would need to ensure that the proposed
design does not interfere with other actions or tasks
the person performs during this activity (e.g., that
the person will not knock his or her elbow on the
grab bar when doffing or donning his or her clothes).
The therapist would also remain mindful of the value
of the activity to the person and, in particular, the
unique elements and methods he or she should aim
to retain when tailoring the intervention to the occupation (e.g., a modification to create a solid backrest
may be required to allow the client to lean back and
relax during toileting, particularly on an accessible
toilet where the distance between the bowl and cistern is usually greater than a standard toilet).
Characteristics of the Environment
The physical, personal, social, temporal, occupational, and societal dimensions, discussed previously in Chapter 1, require careful consideration
when designing and determining interventions. Each
of these dimensions affects how modification recommendations are accepted, used, or rejected by the
clients, their families, and other householders (Aplin
et al., 2015).
The physical environment poses considerable
challenges to intervention planning. Often, the environment can constrain the design of a solution
because there is insufficient space or structural
support for the proposed modification. For example,
therapists are commonly interested in maximizing
circulation space in the bathroom, which is often
achieved by removing other fixtures, such as the
bath, or annexing spaces adjacent to the bathroom,
such as the toilet, and incorporating this space into
the bathroom. If the wall between the bathroom
and toilet is load bearing (i.e., supporting the roof
or upper floor), costly structural work can preclude
this option. The positioning of grab bars can also be
limited by the location of studs (vertical supports
in the wall) because grab bars need to be anchored
directly into studs that sit behind the wall sheeting
or onto solid blocking mounted onto the studs to
ensure the grab bars do not come out of the wall
when used (Adaptive Environment Center, 2002).
Therapists should consult with building and
design professionals if they are uncertain about
whether the environment can support the proposed
intervention. This consultation is vital as there is
often a range of different ways to modify spaces
and provide additional structural support, and the
expertise, insight, and advice of these professionals
can be invaluable in discerning the best potential
option. For example, Figure 9-4 shows a number of
alternatives to securing grab bars directly into studs:
Ô Using special fasteners
Ô Fixing a backing board onto the studs
Ô Installing blocking between studs
Ô Replacing the wall sheeting with plywood that
is at least 3/4 in (19 mm) or more in thickness
Therapists are encouraged to develop an understanding of the physical structure of the built environment so that they have knowledge of the possibilities and constraints for designing environmental
interventions and can effectively discuss alternatives with building and design professionals.
Outside of the structure of the home, there are
further physical aspects that can influence design
and decision making. The ambient conditions of
the home is one consideration that requires careful review. For example, people are often reluctant
to install lifts or alter the placement of windows or
walls if it means they lose a view or natural sources
of light in the home (Aplin et al., 2013). Other considerations might be ensuring people are protected
from weather conditions when entering and leaving
the house by providing roofing to landings and pathways (Aplin et al., 2013). Therapists also need to be
mindful of the impact of changing light conditions
that occur across the day/night and how these might
affect things like safety, ambience, and associated
modification decisions. The location of the home
can also influence decision making. For example, the
topography and geology of an area can influence the
design and placement of ramps and whether earthworks can be used to enhance access to entryways,
a mailbox, or clotheslines. Further, proximity to
public transport, access to shops and other services,
and family and friends are important considerations
when deciding whether to modify the existing home
or to relocate.
Although it is often easy to understand the physical dimensions of the home that affect home modification decisions, it can be challenging for therapists
to develop sufficient understanding of the personal,
social, temporal, occupational, and societal dimensions of the home during a home visit. The impact
Developing and Tailoring Interventions
209
Figure 9-4. Alternative ways to secure grab bars.
of these dimensions often comes to light when discussing alternative options and therapists encounter
clients’ reluctance to modify the home, and in some
cases, active resistance to modification recommendations. During these discussions, therapists come
to understand the clients’ concerns and negotiate
solutions that respect their experience of home.
The personal dimension, the emotional connection with home, has been found to strongly influence
home modification decision making (Aplin et al.,
2013) and requires sensitivity dedicated to the client’s perspective. Having control over one’s home
is key to a positive experience of home, so consequently having choice and control in the home modification process is paramount. The literature consistently reports that successful home modifications
result from consultation and affording clients control
in the home modification process (Aplin et al., 2013,
2015; Hawkins & Stewart, 2002; Johansson, Borell,
& Lilja, 2009; Kruse et al., 2010; Tanner et al., 2008).
The amount of control clients wish to have over their
modification(s) can vary from making choices about
simple aspects such as color or style of fittings to
full control of the project. With the latter, clients are
able to project-manage their modification(s) with
a service, choosing their own materials, products,
and tradespeople/building professionals to complete
the work. In this approach, occupational therapists,
building and design professionals, and other service
providers are viewed as consultants to the client
rather than leading the process.
The appearance is often an aspect of home that is
of importance to clients as it reflects their identity
and promotes their connection to the home. This
aspect of home can be challenging for therapists as it
is not easily observable and can therefore take time
to understand and appreciate. Some clients fear that
modifications will make their home “look disabled”
or “like a hospital” and want to ensure the modifications match the current style of the home (Aplin et
al., 2013). Ensuring that the design of modifications
is aesthetically pleasing and consistent with the
look and feel of the home will often reduce these
concerns, and the implementation of resources such
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Chapter 9
as pictures and videos of potential modifications can
be very useful in assisting clients to visualize proposed changes. Further, although costs are often a
consideration for many clients, it is important to not
make assumptions as sometimes clients are willing
to pay significant additional costs to ensure modifications match their home or provide a less “clinical”
look (Aplin et al., 2013). Further to aesthetics, safety
and security considerations can also affect clients’
willingness to consider or undertake a modification.
For example, a ramp can improve accessibility and
safety when entering or leaving the home; however,
people may be reluctant to have one installed at the
front of the home as it potentially identifies the resident as having a disability and portrays a potential
image of vulnerability to people passing by the home.
Consequently, the therapist might negotiate to have
the ramp installed at the rear entrance. Reducing
the visibility of modifications from the street also
protects a person’s privacy as some clients may
prefer to conceal their disability from others’ awareness or knowledge. Additionally, some clients are
reluctant to have modifications in the toilet or family
bathroom because visitors will potentially be made
aware of the difficulties the client is experiencing.
Furthermore, an en suite bathroom may be a preferred choice to a main bathroom for modification
so the client can bathe and dress in a private space
rather than mobilizing or being transported through
public areas of the home.
Independence is generally the primary goal of
home modifications; however, freedom within the
home is equally important. For example, parents of a
child with a disability often seek to involve the child
in all household activities and may require access
and circulation in spaces such as the kitchen to allow
the child to watch or participate in the preparation
of dinner. Further, although parents might currently
be assisting the child with various activities, they
may want to ensure spaces, fixtures, and fittings
are accessible so they can encourage the child’s
independence as he or she develops. Understanding
these aspects of the personal dimension help to create solutions that are inclusive and promote future
independence.
Social connections and relationships with the
people whom we share and invite into our home are
an important aspect of life. Therapists often consider the requirements of a partner when making
changes in a space. This is most apparent when placing a grab bar in the toilet for an older couple who
differ in height and experience different challenges
rising from the toilet. When designing modifications,
therapists also consider the caregiver(s) and the
demands placed on them when supporting the client in activities. Clients are also often mindful of the
impact of modifications on people who may visit regularly. For example, an older grandmother may be
reluctant to remove a bath to make a shower recess
if it affects the ability of her grandchildren to use the
bathtub when they stay over. When other people and
relationships are not considered, tension can result,
especially when the needs of one member are prioritized over others (Heywood, 2005). Consequently, it
is critical that therapists consider the social dimension of the home, such as other people who also
use the area (e.g. partners and family), visitors, and
any caregivers involved in the completion of homebased activities when making recommendations.
Considering the temporal dimension of home is
also important in home modification decision making as many modifications are costly and fixed or
permanent. The daily routines and cycles of activities in the home are not always evident to a therapist
during a brief home visit. Similarly, the number of
people in the environment and the range of activities
that occur vary considerably from day to day and
across the week. People may be resistant to modifications that disrupt the familiar rhythms of the
household. For example, if the bathroom has been
the same for 20 years, people may be uncomfortable with or reject the modification simply because
it is different from what is known and may disrupt
the order of their home and routine (Aplin, 2013).
Furthermore, clients may be concerned about the
disruption to the home and routine resulting from
modification works, especially those that extend
over a number of weeks. It is important to recognize
that objection or rejection of suggested modifications may be about the change to the home itself
rather than issues of identity, cost, or lack of control
in the process. In these circumstances, it is important to work with the client to come up with solutions that will allow him or her to keep some of the
aspects that are important to them, such as keeping
a particular cabinet, reusing tiles, or painting in the
same color. It is also important that clients are given
the opportunity to process the information provided
and consider alternative options before making a
decision, even if it means that modifications need to
be delayed.
Anticipating changes over time, such as growth in
children or deterioration or improvement in health,
can also ensure that the modifications address client
needs long term. One recurring preoccupation for
clients and families is the impact of modifications on
the resale value of the home (Aplin, 2013). In these
situations, clients can be reassured by information on the removal of minor modifications such as
grab bars. However, if the future needs and wants
of occupants are not considered, clients can be left
with unsuitable modifications and wasted resources
Developing and Tailoring Interventions
(Aplin, 2013). In some circumstances, people may
need to consider whether it might be better to move
to a more suitable home rather than modify their
existing home. Occupational therapists support families facing this decision by providing information
about key considerations, such as the implications
of moving or remaining in the same location, considering proximity to family and services and their
connectedness to their current home. Working with
families to discuss these issues may help to create
solutions that avoid costly errors, both financially
and emotionally, for families.
The meaning of everyday activities within the
home and the roles the client wishes to undertake
(the occupational dimension) also influences home
modification decision making. The way an individual
completes an occupation is important and can affect
design, particularly if different from standard expectations (Aplin et al., 2013). For example, the aforementioned recommendation for the grandmother
to install a shower recess to replace a bath may be
declined if she herself prefers to bathe rather than
shower. Within the home, people participate in a
range of occupations, including but not limited to
personal activities of daily living, that are meaningful to them. For example, access to the garden or
shed may be necessary to participate in meaningful
leisure occupations or be important to maintaining a role of home maintenance (Aplin et al., 2013).
Although many services focus on personal activities of daily living, it is important that therapists
recognize that clients may have other priorities
for modifications and associated resources (i.e.,
money) and choose to focus on occupations that are
considered more important. When using a clientcentered approach, therapists are mindful of meaningful occupations and the positive impact these can
have on clients’ health and well-being. Consequently,
therapists seek to promote safety and independence
in these activities and ensure continued engagement
in these valued occupations.
The societal dimension can have a substantial
influence on home modification decision making
as it shapes the scope of practice of occupational
therapists and what they offer to their clients, and
consequently determines the amount of control and
choice people have over their home modifications.
Occupational therapists are often bound by service
restrictions and guidelines, but they are also responsible for upholding professional ethics and adhering
to professional frameworks that seek to enhance
independence and well-being. For example, a service
might only fund home modifications that improve
safety and independence in personal activities of
daily living and not be concerned about the client’s
211
safety when gardening, which is a meaningful occupation for the client and therefore important to their
health and well-being. Additionally, services may
restrict options by only making a small range of faucet fittings, grab bar styles, or tiles available (Aplin,
2013), limiting client choice and control. Changes to
standard products, materials, and design can lead
to additional expenses for clients; however, the freedom to choose modifications increases acceptance
and enhances the enjoyment and use of the home.
The competing demands between dimensions can
make home modification decision making complicated and solutions difficult to negotiate with clients.
Chapter 12 provides a framework for dealing with
dilemmas that inevitably arise from these complexities in home modification practice.
Another societal influence is building codes and
design standards. Modifications that require structural, building, plumbing, or electrical work are likely
to be subject to building regulations and require
consultation with a contractor or designer. Although
not required in private dwellings, accessible design
standards are often a key consideration for home
modification design and can have an oppressive
impact on modification decision making as some services may not install modifications unless they meet
access standards (Aplin, 2013). Clients have spoken
of their frustrations with service providers who rigidly apply access standards when designing home
modifications and their frustration with therapists
who prioritize standards over the needs, requirements, and specifications of the person (Aplin et al.,
2013, 2015; Tanner et al., 2008). It is important that
therapists have a solid understanding of the access
design standards and their application in residential
settings when negotiating with clients and services.
The appropriate use of access standards in domestic
dwellings is discussed in further detail in Chapter 11.
DEVELOPING ENVIRONMENTAL
INTERVENTIONS
As noted earlier in this and other chapters, the
capacity and potential of the environment to support occupational performance are well recognized.
Changes to the environment can reduce demands on
the person; enhance health; increase safety, independence, and effectiveness of performance; improve
the quality of life and experience; and promote
further occupational engagement. Environmental
changes can also reduce the need to learn new ways
of performing activities and can limit reliance on
assistive devices and on other people.
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Chapter 9
Although therapists are experts in promoting
occupational performance, they tend to be less
familiar with home modification options and the
architectural and technical aspects of the built environment. Consequently, they can feel uncomfortable
proposing environmental recommendations, seeing
themselves as ill equipped to assess the viability of
an environmental solution. Therapists can address
this in a number of ways by:
Ô Liaising with specialists who can advise them
on environmental solution options, including
appropriate products and designs
Ô Using resources targeted specifically at common occupational performance problems in the
home and typical environmental interventions
Ô Using tools that direct them to specific environmental problems and how these can be
addressed
Ô Familiarizing themselves with general resources about designing safe and accessible
environments
Ô Developing expertise in the technical aspects
of the built environment
Ô Using a framework for considering the various
elements in the built environment
Liaising With Specialists
Occupational therapists can refer clients to specialist services for an environmental intervention
or seek advice from other experts, such as more
experienced therapists, design and building professionals, or suppliers of home modification products.
When referring clients to a specialist service, it is
important to provide them with appropriate information and liaise with them about alternative strategies
and assistive devices that have been recommended.
It is often necessary for occupational therapists
to access the expertise of an experienced colleague,
building or design professional, or supplier of home
modification products when designing an environmental intervention. Ideally, it is useful for the therapist, builder/designer, and supplier of products (such
as vertical lifts) to review the property together
because there are often constraints when attempting to modify an existing structure. The most suitable solution is often achieved when the therapist,
builder/designer, and product supplier collaborate
with the client to identify the environmental intervention that will achieve the best person-environment-occupation fit. Remote strategies such as video
teleconferencing have also been used by therapists
with building and design specialists to observe
direct measurement of the client and environment
and examine activity participation in key areas of
the home (Sanford & Butterfield, 2005). This technology allows the therapist, client, and specialists
to discuss concerns in real time without everyone
being physically present at the home and to draw on
the experience and expertise of all parties in negotiating an acceptable solution in a cost-effective and
efficient way.
If it is not possible to visit the property with
the building and design professional or negotiate a remote consultation, tools such as the
Comprehensive Assessment and Solutions Process
for Aging Residents (CASPAR; Sanford, Pynoos,
Tejral, & Browne, 2002) can guide therapists to measure aspects of the environment that designers and
builders need to be cognizant of in order to redesign
or modify the area (Figure 9-5).
Targeted Resources
Targeted resources are generally aimed at assisting clients in identifying problems in the home and
informing them of potential solutions. For example,
the Adaptive Environments Center (2002) has developed the Consumer’s Guide to Home Adaptation,
which can be used by a client, community care
worker, or building and design professional to evaluate needs, identify solutions, plan, and undertake
environmental modifications (Figure 9-6).
Similarly, the Canada Mortgage and Housing
Corporation (CMHC) has developed a number of
useful publications to assist with making homes
accessible and safe, including Accessible Housing by
Design Series (CMHC, 2016a) and Maintaining Seniors’
Independence Through Home Adaptation: A SelfAssessment Guide (CMHC, 2016b).
Box 9-2 provides an extract from the Maintaining
Seniors’ Independence Through Home Adaptation: A
Self-Assessment Guide (CMHC, 2016b) publication,
detailing recommendations for people who experience difficulty stepping into or out of the bathtub.
These publications introduce therapists to the
broad range of environmental interventions available to address specific occupational performance
difficulties in the home for older people and for
people who mobilize using wheelchairs.
Tools for Identifying and
Addressing Specific
Environmental Problems
Tools such as the Housing Enabler (HE; Iwarsson
& Slaugh, 2010) assist therapists in identifying and
Developing and Tailoring Interventions
213
Figure 9-5. CASPAR Part 5, Description of the Home—C, Measurement of Bathrooms. (Reprinted with permission from Extended
Home Living Services, Wheeling, IL.)
214
Chapter 9
Figure 9-6. Consumer’s Guide to Home Adaptation—Bathroom Solutions. (Reprinted with permission from Adaptive Environments
Center. [2002]. Consumer’s guide to home adaptation. Boston, MA: Author.)
measuring problematic design elements in the built
environment. The HE provides therapists with
details of environmental design elements that interfere with the performance of people with a range
of identified functional and mobility impairments.
It also provides the minimum design requirements
according to Swedish accessibility standards. As
noted in Chapter 6, the HE alerts therapists to elements in the physical environment that present
challenges to people with varying functional and
mobility impairments, such as difficulty interpreting information, severe loss of sight, complete loss
of sight, severe loss of hearing, prevalence of poor
balance, incoordination, limitations of stamina, difficulty in moving head, difficulty in reaching with
arms, difficulty in handling and fingering, loss of
upper extremity skills, difficulty bending or kneeling,
reliance on walking aids, reliance on wheelchair, and
extremes of size and weight (see Figure 6-3). Once
potential barriers have been identified, therapists
can focus on removing or modifying the environment to be more accessible (Figure 9-7).
General Environmental
Intervention Resources
General resources on accessible design, such as
the Americans With Disabilities Act (ADA; 1990) and
Architectural Barrier Act (ABA: 1968), accessibility
guidelines (United States Access Board, 2004/2014),
and The Accessible Housing Design File (Barrier Free
Environments Incorporated, 1991), assist therapists
in understanding the design requirements for people
with disabilities and, in particular, people with
mobility impairments. Therapists often refer to the
standards to identify the recommended specifications for particular design elements (e.g., the circulation spaces around various fixtures and fittings,
heights of power points and light switches, and grab
bar specifications, such as diameter, wall clearance,
load capacity, and clearance from the centerline of
the toilet). However, these standards were designed
for public buildings and were aimed to suit the
majority of users. Based on the anthropometrics
of young adults who mobilize independently using
Developing and Tailoring Interventions
215
Box 9-2. Maintaining Seniors’ Independence Through Home Adaptation: A Self-Assessment Guide Item—
Canada Mortgage and Housing Corporation
CMHC has developed Maintaining Seniors’ Independence Through Home Adaptation: A Self-Assessment Guide, which
is designed to assist older people in addressing specific problems in the home environment. This guide details a range of
activities that older people typically experience difficulties with in the home and describes adaptations to address these
difficulties. Activities addressed include getting in and out of the home, using the stairs, moving around the home, using
the kitchen, using the bathroom, getting out of a bed or chair, using closets and storage areas, doing laundry, using the
telephone or answering the door, and controlling light and ventilation. This tool does not attempt to diagnose the specific
cause of the difficulty but provides a range of environmental interventions aimed at reducing difficulty in performing the
tasks such as removing, moving, modifying, replacing, or adding various fixtures and fittings. Example of Maintaining
Seniors’ Independence Through Home Adaptation: A Self-Assessment Guide item:
5.3 Do you have any difficulty stepping into or out of the bathtub?
☐ NO >> If no, go to the next question.
☐ YES >> If yes, check off the adaptations below that would help you.
☐ Install vertical and horizontal grab bars in locations that will best assist you in
entering and exiting the tub.
☐ Ensure the grab bars are well secured.
☐ Install nonslip flooring throughout the bathroom.
☐ Ensure floor mats have nonslip backing.
☐ Install a nonslip surface in the bathtub.
☐ Install a commercial or custom-made transfer bath bench, so that the tub can be
entered from a seated position.
☐ Replace the bathtub with a shower stall or wheel-in shower if stepping over the
tub wall is too difficult or unsafe.
☐ Install a separate shower stall or wheel-in shower if the difficulty is severe.
☐ Modify the tub with a custom cut-out to eliminate the need to lift legs over the
side of the tub.
A vertical grab bar provides
support when entering the tub,
while a horizontal (or angled) bar
helps you to complete the entrance
and lower yourself onto a shower
seat or to the bottom of the tub.
☐ Install a ceiling track or other lift system for use by caregivers to transfer individuals with serious disabilities into the
tub with the appropriate bath seat.
☐ Other (describe).
Source: Canada Mortgage and Housing Corporation (CMHC). Maintaining seniors’ independence through home adaptations: A self-assessment
guide. Revised 2016. All rights reserved. Reproduced with the consent of CMHC. All other uses and reproductions of this material are expressly
prohibited.
a wheelchair, the specifications in these standards
are not always appropriate for occupational therapy
clients, many of whom do not fit the profile on which
these standards were founded. Further discussion
on how the standards are used in home modification
practice is provided in Chapter 11.
There are also a number of resources dedicated
to designing for specific groups; some examples
include the following:
Ô Aging:
É Residential Design for Aging in Place (Lawlor
& Thomas, 2008)
Ô Alzheimer’s and dementia:
É Adapting Your Home to Living With Dementia:
A Resource Book for Living at Home and
Guide to Home Adaptations (CMHC, 2009)
É Alzheimer’s and Related Dementias Homes
That Help: Advice From Caregivers for Creating
a Supportive Home (Olsen, Ehrenkrantz, &
Hutchings, 1993)
É Dementia Centre: Design for Dementia
(HammondCare, 2017)
É Design Innovations for Aging and Alzheimer’s:
Creating Caring Environments (Brawley, 2006)
216
Chapter 9
Figure 9-7. HE Environmental Assessment. (Reprinted with permission from Iwarsson, S., & Slaug, B. [2010]. The Housing Enabler: A
method for rating/screening and analysing accessibility problems in housing [2nd ed.]. Lund & Staffanstorp, Sweden: Veten & Skapen
HB and Slaug Enabling Development.)
É Designing for Alzheimer’s Disease: Strategies
for Creating Better Care Environments
(Brawley, 1997)
É Australia: Guide to Planning Bathrooms and
Kitchens 2015 (Independent Living Centre
NSW, 2015)
É The Dementia Centre: Design Resource
Centre (The Dementia Services Development
Centre, 2012)
É Australia: Livable Housing Design (Livable
Housing Australia, 2015)
É Occupational Therapy and Dementia Care:
The Home Environmental Skill-Building
Program for Individuals and Families (Gitlin &
Corcoran, 2005)
É Universal Design Guidelines Dementia Friendly
Dwellings for People With Dementia, Their
Families and Carers (Grey, Pierce, Cahill, &
Dyer, 2015)
Ô Visual impairments:
É Making Life More Livable: Simple Adaptations
for Living at Home After Vision Loss (Duffy,
2002)
Ô Young people with significant disability:
É New Housing Options for People With
Significant Disability: Design Insights (Ryan
& Reynolds, 2015)
Ô Other country/locality-specific web-based/
electronic resources include examples such as:
É Hong Kong: Universal Design Guidebook
for Residential Development in Hong Kong
(Hong Kong Housing Society, 2014)
É New Zealand: Lifemark (Lifemark, 2017)
É United States of America: Better Living
Design (Better Living Design Institute, 2014)
É United Kingdom: Housing LIN (Housing LIN,
n.d.)
É United Kingdom: Lifetime Homes (Lifetime
Homes, n.d.)
Increasingly, there is an emphasis on designing
homes using a universal approach. Universal design
ensures that features in the home are usable, comfortable, and convenient for everyone in the home,
regardless of ability or life stage. A growing number
of resources describe universal design features for
residential buildings and community environments,
including:
Developing and Tailoring Interventions
Ô Practical Guide to Universal Home Design
(Wilder Research Center, 2002) is a 19-page
booklet that illustrates essential universal
design features for various areas of the home,
including entrance, kitchen, bathroom, laundry, bedrooms, living and dining rooms, storage, garage, doorways and hallways, floors,
windows, and stairs.
Ô Design for the Ages: Universal Design as a
Rehabilitation Strategy (Sanford, 2012) is a book
written for building, design, and health professionals interested in the use of universal design
for the promotion of participation and performance. It considers the influence of universal
design on social and health movements and
demonstrates a focus on reducing segregation
and stigma that has traditionally been associated with many previous design strategies.
Ô Universal Design: Creating Inclusive Environments (Steinfeld & Maisel, 2012) is a text that
provides a comprehensive overview of practices and solutions in universal design. It examines the difference between accessibility and
universal design and the associated relationships with active living and sustainable design.
It is important to note that these resources provide therapists with a vision of what is possible and
an understanding of specific design requirements.
However, they do not generally assist the therapist
in determining the specific design requirements for
an individual or whether the existing environment is
able to accommodate the proposed design elements.
In addition to the aforementioned text and webbased resources, social media and social networking
are means of communication that are widely being
used to share and disseminate information relevant
to environmental interventions and provide support for therapists and professionals working within
applicable fields. These “online interactions” enable
electronic communications through which a wide
range of information related to home modifications
can be shared through web-based media and online
groups, including videos, blogs, forums, chats, networking sites (e.g. Facebook, Twitter), etc. It is
important to consider these as a potential resource
when sourcing information, examining options and
alternatives, and seeking training and support when
working in the field of home modification. However,
it is also vital to be critical of the source and quality of the information that is provided, as the nature
of the internet enables a vast range of people with
varying backgrounds and experience to make claims
and recommendations.
217
Some examples of current social networking
opportunities include:
Ô Association of Consultants in Access Australia,
available via Facebook and Twitter
Ô Australian Network for Universal Housing
Design, available via Facebook and Twitter
Ô Centre for Universal Design Australia, available
via Facebook, Twitter, and LinkedIn
Ô HomeMods4OT, available via Facebook
Ô Home Design for Living, available via Facebook,
Twitter, and LinkedIn
Developing Expertise in the
Technical Aspects of the Built
Environment
Some therapists find it useful to invest time reading or studying the technical aspects of the built
environment to assist them in understanding building structures and systems that affect modification
design. Additional knowledge assists therapists to
communicate more effectively with building and
design professionals and enables them to identify
whether a solution is viable before referring to a
builder/architect for a work design or quote. For
example, if the therapist knows that the existing
wall in the toilet is unable to support the installation
of grab bars in the required location, he or she can
discuss alternative options with the client or prepare the client with information about the structural
work required to install the grab bars. It is, however,
unwise for therapists who do not have formal building qualifications to provide advice that is outside
of their area of expertise. Occupational therapists
understand the person-environment-occupation
transaction but do not necessarily have knowledge
of specific products, design and construction techniques, systems and structures, or building legislation. It is always advisable for therapists to seek
further advice when environmental interventions
require building or design expertise.
Framework for Dealing With
Elements in the Built Environment
A deeper understanding of the built environment
will assist therapists to appreciate the impact of the
environment on the person-environment-occupation
transaction. Therapists have a sound understanding of body structures and functions that allows
them to understand the impact of impairments on
function. They also possess a deep understanding
218
Chapter 9
Figure 9-8. Structure of a stud wall.
of occupational performance that allows them to
analyze the value and elements of various activities.
A richer understanding of the environment and the
elements within an occupational performance space
and their associated structure will help therapists
recognize the limitations of the existing environment. This assists in determining what can be
altered and how it can be improved to support occupational performance. This understanding will also
enable therapists to collaborate with builders and
designers in developing modifications that fit with
the person, the occupations he or she undertakes in
the space, and the realities of the built environment.
Elements in the built environment that need to be
considered when designing modifications include:
Ô Building structures
Ô Service systems
Ô Spaces and places
Ô Products, devices, and technologies
Ô User interfaces
Building Structures
Therapists need to appreciate the importance of
structures in the built environment when developing environmental interventions. The structure of a
house is found in the framework, which is composed
of four basic parts: floors, walls, ceiling, and roof.
In modification work, therapists are mostly interested in moving or removing walls or adding, modifying, or repositioning fixtures and fittings on walls,
so it is important to understand how they are constructed and the functions that walls perform.
In most houses, walls are constructed using 2-in ×
4-in (50-mm × 75-mm) timber. They consist of a frame
with studs or vertical lengths every 16 in (450 mm)
to 24 in (600 mm) along the length of the wall. This
frame is then covered with some type of sheeting,
such as plywood, particleboard, fiberboard, plasterboard, or some other drywall material (Figure 9-8).
Increasingly, stud walls are being constructed
from steel rather than timber, which has implications
for whether fixtures and fittings can be attached and
what extra reinforcement or fixings are required.
Walls can also be constructed of concrete blocking
or masonry (brickwork), which is more difficult to
remove or modify and requires special tools and
fasteners to install fittings and fixtures. When items
such as grab bars are installed on a wall, they need
to be secured into the studs or other structural supports in the wall. The nature and location of these
structures can determine whether a grab bar can
be safely attached and where it or other accessories
can be located. Alternative structural supports can
be put in place if the wall structure is inadequate or
if the studs are not located in the required positions;
however, the advice of a suitably qualified building
contractor or designer should be sought if there are
concerns about the capacity of the wall to support
these fittings.
Although walls are mostly used to divide up interior spaces, some walls are load bearing and serve the
additional function of supporting an upper floor, ceiling, and/or roof. Therapists need to be aware that a
supporting or load-bearing wall cannot be removed
without being replaced by a suitable support structure. This type of alteration requires the expertise of
a building or design professional and can be costly.
When considering any structural modification, it
is advisable to employ a building or design professional to inspect the building to ensure that it is in
good repair and able to accommodate the recommended changes. It is also essential to know what
is behind the surfaces of walls, floors, and ceilings
before work begins to avoid damage to service
systems such as electrical wiring, plumbing, and
ducting.
Service Systems
The service systems within a home include plumbing; wiring or the electrical system; and the heating,
ventilation, and air conditioning system. Plumbing
in residential structures involves the water supply
system as well as the drainage system. The home’s
electrical system is made up of wiring, outlets, and
switches and has many circuits, each of which starts
from a main service panel. The heating, ventilation,
and air conditioning system includes the heating or
Developing and Tailoring Interventions
219
Table 9-2. Common Attributes of Physical Environment Features Proposed by Sanford and Bruce (2010)
SPACES AND PLACES
•
•
•
•
•
•
•
•
Entry
Circulation/level changes
Orientation cues
Configuration/layout
Location of products, devices, and technologies
Location of environmental controls
Ground/floor and wall materials/finishes
Ambient conditions
PRODUCTS, DEVICES,
AND TECHNOLOGIES
•
•
•
•
•
USER INTERFACES
Product type
Dimensions
Weight
Location of user interfaces
Materials/finishes
•
•
•
•
•
•
•
•
Type of interface
Minimum approach
Distance and angle
Dimensions
Activation force required
Operational attributes
Materials/finishes
Feedback mechanisms
Reprinted with permission from Sanford, J., & Bruce, C. (2009). Measuring the physical environment. In E. Mpofu & T. Oakland (Eds.), Rehabilitation and health assessment (pp. 207-228). New York: Springer.
cooling unit as well as a series of ducts leading to
and from various rooms in the house. Each of these
systems has lines (pipes, wiring, and ducts) that run
through the wall, floor, and ceiling cavities, which
need to be considered when proposing changes.
Due to the potential for service systems to be
housed in walls, it necessary that care is taken
when securing fixtures and fittings to the wall.
Furthermore, it is important to note that these
systems will also need to be relocated if the wall
is being moved or removed. In some buildings, it is
extremely costly or impossible to relocate systems,
such as electrical wiring, power outlets, water pipes,
and sewage and waste outlets. For example, relocating a toilet or a waste outlet in the bathroom would
require the drainage pipes and outlets in the floor
to be repositioned. Where this is possible, it can be
costly, and in some constructions, such as a slab-onground construction, it is difficult to undertake such
changes. Consequently, when looking to remodel a
bathroom, for example, it is advisable to note the
location of existing fixtures and fittings and plan to
keep them in those locations or to account for the
cost in relocating them when discussing the relative
merit of designs and installations.
Though therapists are not required to possess
this building knowledge, it is important that they
are aware of some of the limits to what is possible
and seek the advice of a suitably qualified builder,
designer, or contractor when investigating modifications that require changes to the building structures
or systems.
When working within the existing structure of
a home, a number of design elements can affect
occupational performance. These elements, or attributes, of the physical environment have been identified as spaces and places; products, devices, and
technologies; and user interfaces (Table 9-2; Sanford
& Bruce, 2009).
Spaces and Places
When considering the impact of the environment
on occupational performance, it is useful to examine
the spatial elements of the environment and whether
these elements need to be altered to promote performance. Sanford and Bruce (2009) identify key spatial
considerations to include the following:
Ô Entry: Can the person approach the entry and
negotiate the clearance through the doorway
safely and efficiently?
Ô Circulation/level changes: Is there adequate
room for the person to move, approach, reach,
and use various fixtures and fittings in the
room? Are there any changes in levels to negotiate between areas?
Ô Orientation cues: Is signage clear and appropriately located? Are key landmarks well lit, visible, and located in a logical position?
Ô Configuration/layout: Is the layout logical in
terms of the way the person uses the space?
Does the size of the spaces, configuration, or
layout allow the person and/or caregivers to
maneuver equipment? Do these allow flexibility
in use of space?
Ô Location of products, devices, and technologies: Are the switches, outlets, and fixtures visible, accessible, and located in a logical place?
Ô Location of environmental controls: Are the
controls visible, accessible, and located in a
logical place? Can they be operated or adjusted
easily?
220
Chapter 9
Ô Ground/floor and wall materials/finishes: Are
the floor materials appropriate for the activities being undertaken and the people using the
space? Do the materials used create a suitable
look and feel? Do the materials used assist in
differentiating spaces for different purposes?
Do the wall materials provide flexibility in supporting future fixtures and fittings?
Ô Ambient conditions: Is the lighting adequate for
the tasks being undertaken, and is it located in
the appropriate area? Is the room a comfortable
temperature for the activity being undertaken?
Products, Devices, and Technologies
Products such as fixtures, appliances, and
building elements (e.g., flooring, doors, and windows) have characteristics that affect ease of use.
Considerations identified by Sanford and Bruce
(2009) include the following:
Ô Product type: What products does the user
need to interact with?
Ô Dimensions: Do the fixtures fit into the space or
location available (leaving adequate room for
approach and operation)?
Ô Weight: Can the fixtures and fittings be moved
if required?
Ô Location and size of user interfaces: Can the
controls on the fixture be reached and operated easily? Are they visible and well lit? Can
they be easily read?
Ô Materials/finishes: Do the materials and finishes provide appropriate contrast, friction,
or resistance? Can the fixtures and fittings be
operated using limited force/dexterity? Do the
fixtures and fittings provide adequate auditory
and/or visual information to the user? Are they
comfortable to use (temperature and texture of
the surface against the skin, etc.)? Will materials and finishes stand up to the anticipated
wear (to suit heavy equipment use or impact
by equipment)?
User Interfaces
User interfaces include controls and hardware
such as handles, knobs, faucets, locks, and handrails
and grab bars. Electronic and mechanical controls
and dispensers also affect use. Key considerations
identified by Sanford and Bruce (2009) include the
following:
Ô Type of interface: What controls and hardware
does the user need to interact with?
Ô Minimum approach distance and angle: Can the
controls/hardware be accessed easily?
Ô Dimensions: Do the controls fit into the space
and location available (leaving adequate room
for approach and operation)?
Ô Activation force required: Can the controls/
hardware be operated using limited force/
dexterity?
Ô Operational attributes: What is the direction
and distance that controls/hardware need to be
moved? Can they be easily read and operated?
Ô Materials/finishes: Do the controls/hardware
provide adequate contrast/friction? Are they
comfortable to use (temperature and texture
of the surface against the skin, etc.)? Will they
tolerate the way they are likely to be used?
Ô Feedback mechanisms: Do the controls/hardware provide adequate auditory and/or visual
information to the user?
The number of design elements that require consideration can be overwhelming for new therapists.
Consequently, checklists and frameworks for considering these elements systematically are quite useful. However, when attempting major modifications,
the expertise of a designer or builder is essential.
Therapists should not take responsibility for determining the suitability or integrity of the existing
building for modification. They should, however,
have sufficient understanding of the built environment to be alert to its limitations to enable them
to collaborate effectively with builders and designers and to ensure that their recommendations are
reasonable, the needs of the client are adequately
addressed in the redesign, and the modifications do
not present any unanticipated difficulties or complexities for the people living in the home.
CONCLUSION
This chapter has described the range of performance issues that older people and people with
disabilities experience in the home and the range
of intervention strategies occupational therapists
use to address these issues. It has introduced a
framework for analyzing the resources used during
activities and identifying ways in which alternative
strategies, assistive devices, social supports, and
environmental modifications can address occupational performance concerns and further facilitate
the person-environment-occupation transaction.
The role of occupational analysis and clinical reasoning in designing client-centered interventions
has also been examined. In particular, this chapter
described considerations in determining the most
Developing and Tailoring Interventions
suitable intervention and tailoring it to the specific
needs of the person, activity, occupation, and environment. Finally, this chapter has detailed the range
of environmental interventions used to address
occupational performance issues in the home and
provided therapists with mechanisms for developing
their understanding of the built environment.
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society: Innovative approaches. Bristol, UK: Policy Press.
Peek-Asa, C., & Zwerling, C. (2003). Role of environmental interventions in injury control and prevention. Epidemiologic
Reviews, 25, 77-89.
Pettersson, C., Löfqvist, C., & Malmgren Fänge, A. (2012). Clients’
experiences of housing adaptations: A longitudinal mixedmethods study. Disability and Rehabilitation, 34(20), 1706-1715.
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health assessment (pp. 207-228). New York: Springer.
Sanford, J. A., & Butterfield, T. (2005). Using remote assessment
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Gerontologist, 45(3), 389-398.
Sanford, J. A., Pynoos, J., Tejral, A., & Browne, A. (2002).
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10
Sourcing and Evaluating
Products and Designs
Desleigh de Jonge, MPhil (OccThy), Grad Cert Soc Sci and
Melanie Hoyle, BSc (Psych), MOccThySt, Grad Dip Health Sci, Post Grad Dip Psych
Therapists use a wide range of mainstream and
specialized products and design solutions to address
a variety of occupational performance concerns and
difficulties. Consequently, they need access to a
number of different information systems to locate
information on what is available. They also need
to be able to evaluate the relative benefits of each
option to determine the best solution for each client
and his or her household. The first section of this
chapter overviews the information systems therapists can use to gain an understanding of environmental interventions and then examines the nature
of information provided by each of these systems.
Therapists can use these resources to locate suitable options for individual clients, to enable them
to remain informed about developments in the area,
and to build a body of knowledge about the range of
interventions available.
The second section of this chapter outlines a systematic process for reviewing and comparing products and designs and details considerations when
evaluating the relative merits of various options.
It identifies the information therapists require to
undertake a thorough comparison of options and
discusses the unique perspective clients bring to
the decision-making process. It also highlights the
benefits of drawing on the experiences of other
therapists, designers, builders, and clients to understand the advantages and disadvantages of various
products and designs. The role of evidence and
standards in reviewing the suitability of options is
also discussed, as are the evolution and principles
of good design, which strive to ensure that products
and designs used for older people and people with
disabilities are aesthetic, flexible, and functional in
the long term.
CHAPTER OBJECTIVES
By the end of this chapter, the reader will be able
to:
Ô Identify and discuss the benefits and limitations of various information systems used to
gather information on products and designs
Ô Describe a systematic process for reviewing
products and designs
Ô Identify key issues in evaluating the potential
value and effectiveness of product and design
solutions
Ô Describe the development of design and the
implications of design approaches for older
people and people with disabilities
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Guide to Home Modification Practice, Second Edition (pp. 225-246).
© 2019 SLACK Incorporated.
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SOURCING
PRODUCT
EVALUATING
DESIGN OPTIONS
AND
AND
When developing environmental interventions,
therapists draw from a broad range of products and
design solutions, including specialized and mainstream options. Consequently, they need access
to information on specialized assistive devices for
people with various functional impairments as well
as the many generic building products on the market. They also need to understand various design
approaches and be able to evaluate their suitability
for each situation. Because there is an ever-increasing number and range of options and information on
these is scattered across industries, information systems, and suppliers, it is often difficult for therapists
to feel confident that they have a good understanding of all the options available.
Information on Products and
Designs
To develop effective interventions, therapists
need to actively develop their understanding of the
broad range of specialized and mainstream options
available. They need to know where to find information on products and designs and how to search for
solutions suited to the unique requirements of each
client. It is therefore important that therapists are
aware of the information systems available and can
use these effectively to locate suitable options for
individual clients.
When searching for potential options, these questions come to mind:
Ô What products and design options exist?
Ô Where are they available?
Ô Who were they designed for?
Ô How well will they suit the person’s identified
needs?
Ô How long have they been tested and available
in the marketplace?
Ô Why choose one product over another?
Therapists need a good understanding of the
range of options available and their specifications,
such as size, shape, weight, and finish. They need to
know where they are available and how much they
cost. It is also important to be familiar with who the
product was designed for because this gives therapists an indication of its potential strengths/limitations and the situations it best suits. Therapists
should also have knowledge of how the product can
be adjusted or customized as well as understand its
installation, maintenance, and service requirements.
Ultimately, therapists need to be able to specify performance criteria of the recommended product type
and explain why these specifications are best suited
to the situation. In the case of a legal challenge,
therapists need to be able to defend their recommendations. To answer these questions, therapists need
to access a range of resources to gather information.
These include the following:
Ô Company catalogues
Ô Trade exhibits or information and display
centers
Ô Databases
Ô Online resources: Dedicated home modification
websites, as well as building, government, and
community websites concerned with home renovation, modification, repair, and maintenance
(e.g., checklists, buyers’ guides, renovation
guides, and product reviews)
Ô Professional publications and resources: Books,
journals, and newsletters
Ô Conferences and workshops
Ô People with experience: Clients, professional
colleagues, builders, and designers
A list of some potential online resources is available in Appendix E.
Company Catalogues
Many specialist and mainstream building suppliers provide catalogues of their products, either in
hard copy or online. These resources answer the
“what” and “where” questions well because they
can provide good graphics and specifications of the
products in their range. They can also provide an upto-date price list and the contact details of suppliers
in various locations. Generally, companies supply a
defined range of goods, which means that therapists
need to access a number of companies’ catalogues
to understand the full range of options available. The
clear photos or drawings of each product generally
provided can be used when describing alternatives
to clients. Sales representatives might also be able
to provide a sample of the product to view or test in
various situations. It is important to remember that
sales representatives are paid to promote their products, so they will be able to describe the features
and identify all of the advantages of their products.
A discussion with representatives from a number
of companies is usually required to develop a full
understanding of the relative strengths and limitations of all options on the market. Company representatives may also be able to provide information
Sourcing and Evaluating Products and Designs
on whom the product was specifically designed for
or situations where it is best suited. Additionally,
they usually have knowledge of legislative requirements regarding installation such as council requirements, access standards and/or work health and
safety compliance. Therapists would then need
to ascertain whether the product would meet the
specific requirements of each client and meet his
or her particular needs. Catalogues are useful for
therapists who have a clear understanding of the
requirements of the client and his or her situation
and well-developed professional reasoning skills
that allow them to filter and analyze the information
provided. Therapists with a good knowledge of the
range of options should also ensure that they access
catalogues from all relevant suppliers and not limit
themselves to a restricted range of alternatives. It is
also advantageous to have some experience with the
application of the products or access to people who
have used them so that sales information can be balanced with an understanding of how well products
work in various situations.
Trade Exhibits or Display Centers
Trade exhibits or information and display centers
are an excellent way for therapists to develop an
overview of the range of products available and to
keep up to date with recent developments. These
resources provide therapists with similar benefits
and challenges; however, having a number of companies and products co-located makes it easier to
gather information on a range of options and to
view and compare alternatives. It should be noted
that, although these exhibits and display centers
have many products on display, they might not be
comprehensive or representative of all the products
available on the market. They are likely, however,
to showcase local suppliers and contractors, which
is advantageous to people who are unfamiliar with
resources in the area or who live in more remote
areas where such resources are often scattered.
Databases
There are many specialist and mainstream databases that allow therapists to search for specific
products. Most of these are now available online;
however, some require subscription or membership. The advantage of using a database is that
many of them feature consistent fields to describe
the various products they have on file. This allows
therapists to quickly access information on a range
of options and compare specifications and costs. It is
sometimes possible to search for products with specific features, thus allowing therapists to define their
search and locate suitable products quickly. The
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amount of information and graphics provided varies, and the currency of the information depends on
how regularly the database is updated. Some of the
information provided may be location specific, so it
is important to use databases that have information
on products from the appropriate region. Therapists
with sound clinical skills and a clear idea of what
they want from products are well placed to maximize
the use of these resources. The volume of information available can be overwhelming for therapists
who are new to the area. Once again, it is advantageous to have some experience with the application
of the products or access to people who have used
them so that information can be augmented with an
understanding of how well the products work in various situations.
Online Resources
There are many dedicated home modification and
building websites, as well as government and community websites that display a variety of resources
related to home renovation, modification, repair, and
maintenance. With the increase in the aging population, and disability and aged care reforms occurring
in many countries, there has been an explosion
of resources designed to assist older people and
people with disabilities in identifying and addressing their home modification and maintenance needs.
Many checklists, buyers’ and renovation guides, and
product reviews can be uncovered with an online
search engine. Several of these resources have been
written specifically to assist the target population
to identify and address their safety and function
in the home as they age. In addition, a number of
resources outline how to make homes accessible
for people using wheelchairs or manageable when
caring for someone with dementia. These resources
can be particularly useful for clients and therapists
because they provide an overview of issues and an
introduction to potential solutions, especially lowcost options. They may or may not provide details
of specific solutions or products and, if they do,
the information may be location-specific. These
resources can be useful for clients and novice therapists; however, it is important that therapists check
the authority of these sites by confirming, against
other resources, the expertise of the authors and the
validity of the information provided. It is also advisable to be aware of the domain of the website and to
interpret the information accordingly. For example:
Ô .com is a commercial site
Ô .org is a community organization
Ô .edu is an educational institution
Ô .gov is a government site
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Further, there are also a range of social media
and social networking sites (refer to Chapter 9) that
enable clinicians to disseminate and review information and connect to share and discuss issues and
gain collegial support respectively. Each of these site
types has a function and perspective that need to be
considered when assessing the authority and validity of the information provided. Therapists need to
dedicate time to becoming familiar with, and regularly reviewing, resources on the internet. Experienced
therapists are well placed to piece together these
scattered resources and direct new therapists and
clients to the best resources available.
Professional Publications and Resources
There are an increasing number of books, journals, newsletters, and websites that provide information related to home modifications. Books written by
occupational therapists and other industry-related
professionals on home modifications provide therapists with an understanding of a range of solutions;
however, the qualifications and experience of the
authors, the frames of reference from which they
operate, and the focus of the book can define the
range of options presented. For example, occupational therapists will generally seek to define the specific needs of the client before detailing the potential
options. They also see environmental interventions
as part of a suite of interventions and will, therefore, discuss these in conjunction with alternative
strategies, assistive devices, and supports. On the
other hand, books written by building and design
specialists will provide details of alternative designs
without necessarily identifying who they best suit or
alternatives to costly renovations. However, these
texts allow therapists to develop their understanding of the range of options and necessary considerations when designing environmental solutions.
Books do not generally refer to specific products but
might provide a list of suppliers relevant to the location of the publication. It is important, however, to be
aware that the information may be dated, given that
books generally are not frequently revised. A range
of books has been written on aspects of home design
for people with specific requirements, including
older people, people with dementia or vision impairment, or wheelchair users. Some books focus exclusively on low-cost modifications to existing premises
and others describe design elements that need to
be incorporated into the design of a new home or in
extensive renovations of an existing home.
Journals and newsletters might also discuss and
evaluate various intervention approaches or provide
reviews of products. Several websites are dedicated
to home design, construction, and modification.
These sites are a repository for publications, reviews,
and information on training and education opportunities, and they often provide links to other relevant
sites.
By monitoring these information resources, therapists can develop a broader understanding of the
effectiveness or usefulness of various interventions
and products and can search for more specific
details when relevant situations arise. Therapists
who need an overview of the area and an understanding of the range of possible solutions available
will find such resources invaluable; however, they
would also need to ensure they are well informed
about current products and design approaches in
their local area.
Conferences and Workshops
Conferences and workshops are useful in assisting therapists to understand the range of interventions, approaches, and products available and in
helping to develop an awareness of existing services
and expertise. The location of the conference or
workshop and the background and experience of the
presenters might be considerations in applying the
information directly to clinical practice. Therapists
might need to evaluate whether the approach, products, or designs are well suited to the needs of their
client group and location. These resources provide
therapists with benefits and challenges like those
provided by professional publications and resources; however, novice therapists might find workshops
a more efficient way of getting the basic knowledge
and skills they require because the expert presenters often collate current information from a range of
resources and tailor it to the background and level of
experience of the workshop participants. More experienced therapists are well equipped to use information presented at conferences and will benefit from
having access to the range of home modification
experts and exhibitors who attend international,
national, and regional conferences.
Specialist Education and Training
Home modification practice requires therapists to
develop specialist skills and knowledge. In addition
to identifying occupational performance difficulties
in the home and addressing these using alternative
strategies, assistive devices, and social supports,
therapists are required to understand how and when
the environment can be modified. Many therapists
seek additional training or courses to extend their
knowledge of the built environment. These courses
introduce therapists to building practices, various
design approaches, products, and finishes and show
how to navigate funding systems and modification
Sourcing and Evaluating Products and Designs
services and manage building processes. This understanding complements the clinical knowledge therapists have and the reasoning they use to address
occupational performance difficulties and concerns
in the home. Additionally, it enables them to work
more effectively with designers and builders in
developing effective home design solutions.
People With Experience
Clients, professional colleagues, builders and
designers, and suppliers with experience designing, supplying, or using home modifications can be
invaluable in assisting therapists to identify alternatives or select and tailor environmental interventions to individuals’ needs. With the explosion of
social networking, social media, and communication
technologies, therapists have ready access to a
diverse group of people with expertise and experience. Discussing situations with professional colleagues or building and design professionals can
help clarify issues and solve problems associated
with difficult scenarios. People with specialist skills
and knowledge or experience using products and
designs over extended periods can provide insights
into what does and does not work well in different
situations. They often have extensive knowledge of
the products and designs that can be supported
locally and the quality of after-sales and maintenance services for various products. Older people
and people with disability who have experience with
negotiating environments and living with products
and designs also have a wealth of valuable experience and knowledge from which to draw. These
resources are of value to novice and experienced
therapists alike, allowing them to make use of the
experience of others to complement their own skills
and knowledge and develop the best possible solution for their clients.
Reviewing Product and Design
Alternatives
Once the range of alternative products and designs
has been identified and located, each option must be
evaluated to determine the best one for each situation. When evaluating the suitability of designs or
products, therapists need to ask the following:
Ô For whom has the product/design been
developed?
Ô How well will the product/design meet the client’s specific requirements?
Ô How long has the product/design been tested
and available in the marketplace?
229
Ô Why choose one product/design over others?
There are many considerations when examining
the origin of products and designs. First, design and
product requirements can vary between countries
and regions. Therapists need to ensure that designs
and products they recommend meet the requirements of their national and local standards or building codes. For example, design standards or building
codes for a region with a low-density population,
high winds, or low rainfall might not reflect the
standards of a region with a high-density population
and heavy snowfall. Second, commercially available
products are generally designed for the mainstream
market and might not acknowledge the diversity of
function in the broader population. Therapists therefore need to be mindful of the needs of their client
group and individual circumstances when assessing the suitability of various mainstream products
and designs. For example, many fittings require fine
motor control that can be problematic for older people and people with disabilities. In addition, labels or
indicators are often difficult to see or read, and even
specialized products or designs can be developed
with one disability group in mind. For example, products and designs developed to address the needs of
wheelchair users with full upper limb function might
not readily address the needs of people with other
disabilities.
When choosing the most suitable product for a
client or situation, therapists need to think about the
client’s specific situation and consider the strengths
and limitations of each option in relation to their
requirements. Each product or design should be
evaluated in terms of how well they will:
Ô Be used by the client, given his or her physical,
cognitive, sensory, and emotional capacities
Ô Enable the client to complete the occupation in
his or her preferred manner
Ô Fit with the physical, personal, social, temporal, occupational and societal dimensions of
the environment.
In addition, each option needs to be compared in
terms of the following:
Ô Product features and specifications
Ô Clients’ priorities and preferences
Ô Experience of the product or design
Ô Existing evidence of the benefits of the product
or design
Ô Conformity with design or product standards
or building code requirements
Ô Good design practice
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Furthermore, it is beneficial to know how long
the products and designs have been available in the
marketplace. This will provide information about
whether the product, for example, has been tried
and tested extensively, whether there is likely to be
service support for setup and maintenance/servicing, whether parts are available, and whether there
are people who can comment on its suitability for
their circumstance. Such knowledge will guide practice decisions about a product’s application and use.
Product Features and Specifications
When reviewing products and designs, it is useful
for therapists to gather information on the features,
specifications, and cost of each option so that they
can be systematically compared. Therapists often
develop templates that allow them to gather all the
information they need when considering the suitability of options. These templates can include:
Ô Name of product and a description
Ô Models
Ô Appearance, a graphic
Ô Specifications
Ô Price range
Ô Warranty
Ô Construction (what the product is made of)
Ô Installation requirements
comparing options and ensure that the comparisons
account for the long-term impact of solutions as well
as immediate expenses.
Consumers’ Priorities and Preferences
Clients are often not afforded sufficient choice
and control over the home modification process,
which can result in them feeling disempowered
(Aplin, de Jonge, & Gustafsson, 2015; Hawkins &
Stewart, 2002; Heywood, 2004; Sapey, 1995) and dissatisfied that their priorities and preferences are not
reflected in the outcome. Professionals often have
knowledge of and experience with a range of products and designs and have assessed their functional
suitability. However, clients are best placed to evaluate how suitable the products or designs would be
for his or her situation and how well they will fit with
the look and feel of the home, the people who live
there, and the many activities that are undertaken
in it. Clients can often have quite different views of
their homes and needs to service providers, and this
can impact on how they value advice and their willingness to proceed with recommendations (Aplin et
al., 2015; Auriemma, Faust, Sibrian, & Jimenez, 1999).
It is therefore crucial that the client’s experience of
home is valued during this decision-making process.
When clients are evaluating products and designs,
they are most often concerned with the following:
Ô Appearance
Ô Care and maintenance requirements
Ô Cost
Ô Advantages and limitations
Ô Longevity (including suitability over time and
accommodation of future needs)
Ô Compliance with relevant standards or building
codes
Ô Suppliers and services able to fit and maintain
the product
Ô Notes regarding supply (e.g., availability and
after-sales support)
When considering the cost of interventions, as
well as the original purchase price, it is also important to consider the installation, maintenance, and
replacement costs (Andrich, 2002). Further, the
social cost of various options also needs to be
examined (Andrich, 2002). For example, the cost of
formal or informal support as an alternative to the
product or design can be prohibitive. Although the
cost of formal support can be readily calculated,
the cost of informal support can be overlooked.
Therapists need to be mindful that it might be more
cost-effective to employ a product or design rather
than recommend the provision of formal or informal
support as an alternative (Chiatti & Iwarsson, 2014;
Heywood & Turner, 2007; Scottish Government, n.d.).
These issues are important considerations when
Ô Safety
Ô Privacy
Ô Support meaningful activities and routines
Ô Availability
Ô Functionality or usability
Ô Independence
Ô Impact on other household members or visitors
Ô Adaptability and suitability
Ô Installation or construction requirements
Ô Care requirements
Ô After-sales support
Ô Anticipated lifespan
Modifications can sometimes have a clinical
appearance, which might not fit well in the home
environment (Duncan, 1998). Complying with design
standards or building codes designed for public
buildings and spaces can also result in modifications
having an institutional appearance, which is not
Sourcing and Evaluating Products and Designs
generally in keeping with residential environments
(Lund & Nygard, 2004). Furthermore, clients report
frustration when service providers adhere to building codes which can result in modifications that do
not suit his or her preferences and needs (Aplin et
al., 2015). It is important that products and designs
are well suited to a domestic situation, are in keeping with the style and décor of the client’s home and
reflect personal preferences. When deciding on modification designs, in the forefront of clients’ minds is
often their wish for enhanced safety, privacy, and
independence (Aplin, de Jonge, Gustafsson, 2013).
Modifications, therefore, must provide safety and
consider the need for privacy. This includes both the
privacy needs for private activities such as toileting
and bathing, but it also extends to having a private
space of one’s own in the home.
Though clients are often mindful of the costs
associated with home modifications, they are also
likely to want quality products, designs, and finishes in their home. Many therapists can let the
expectations and restricted financial resources of
the subsidizing organization determine their choice
of products and designs (Rousseau, Potvin, Dutil,
& Falta, 2001). However, the cheapest option is not
always the best value. Additionally, the future is
an important consideration for clients where, for
example, deteriorating health or the growth of the
child should be accommodated in designing modifications (Aplin et al., 2013). Modifications that do not
fully satisfy the current and anticipated needs of the
household can result in wasted expenditure (Home
Adaptations Consortium, 2013). Householders often
have pragmatic concerns when reviewing alternative options. Once they decide to proceed with the
modification, they want to ensure minimal delay and
disruption. Consequently, they might show a preference for products that are readily available and
choose designs that have been used locally, especially if they can view the finished product prior to
confirming choice.
Another important consideration is usability, or
the extent to which an individual’s performance
and activity patterns can be fulfilled in an environment (Bernt & Skar, 2006). Potential usability is
best judged by the individual who will be using the
product or space and is likely to be influenced by
his or her experiences and expectations (Steinfeld
& Danford, 1999). Because performance and activity
patterns can vary from day to day or throughout the
day, it is important to consider the capacity of the
product to support or to be adjusted to account for
these variations. Further, clients will seek modification designs that will provide the most opportunity
for independence and freedom in the home (e.g.,
231
freedom of movement and ability to have choice in
what activities they do at home; Aplin et al., 2013).
When there are a number of people using the product or space, its ability to accommodate all users
needs to be examined. This includes the potential
impact of the product or design on other household
members as well as regular visitors.
The installation or construction requirements
might also be a matter for consideration when
reviewing alternatives. Some clients find it difficult
to tolerate major disruptions to their routines or
households and might prefer an option that is less
intrusive in the short term. It is therefore important
that they are made aware of potential disturbances
associated with product and design choices. In
addition, the care requirements may prove problematic for some clients. For example, although textured
flooring provides good grip and reduces the risk
of slipping, it is more difficult to clean, especially
for people with reduced mobility and upper limb
strength. Over time, the buildup of soap and grime
can make these floors more hazardous.
The availability of after-sales support for products
or the construction is also of interest to clients, who
are often responsible for the repair and replacement
of the modification to his or her home. Clients wanting value for money will also be concerned with the
lifespan of the product. Selecting a product with a
longer lifespan, even if it costs more initially, might
be preferable and less expensive in the long term.
Experience of the Product or Design
Therapists, designers, and builders with extensive
experience in home modifications can draw on this
wealth of knowledge when selecting products and
designs. They usually know how well a product or
design works in various situations and the range of
people who have used the intervention successfully.
These professionals may also be aware of difficulties
encountered in acquiring, installing, adapting, or getting approval for a solution in a variety of situations
or locations. Experienced therapists, designers, and
builders can, similarly, have a good understanding of
the lifespan of products and designs that have been
used over time. This information assists in anticipating how well certain materials and finishes can stand
up to wear and tear in a range of situations.
Follow-up with clients provides therapists with
information on the usability of interventions, care
requirements, and the responsiveness of after-sales
support. Seeking feedback from clients and monitoring their experience over variable periods is an
effective way of accumulating experience of various
products and designs. This enables therapists to
gain a richer understanding of the application of
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products and designs in a range of situations. It is
especially valuable in identifying any unexpected
issues in relation to the following:
Ô Acceptance
Ô Cost
Ô Functionality or usability
Ô Adaptability and suitability
Ô Installation or construction
Ô Care and repair
Ô After-sales support
Ô Lifespan
As noted previously, these issues are also important considerations for clients.
Therapists often encounter challenging situations
that require products or designs with specific features and functions. Those with limited experience
can benefit greatly from discussing options with
their more experienced colleagues. Listservs and
social networking sites where people come together
online to discuss issues can be an effective medium
for therapists seeking information and opinions from
a wide range of experienced people. Useful information can also be gained from examining products
and designs in public environments that receive
extensive use. Products and designs commonly used
in the building industry can also give an indication of
their reliability and cost-effectiveness.
Existing Evidence of the Benefits of the Product
or Design
Therapists draw on a range of evidence when
designing interventions and evaluating the suitability of various products and designs. Evidence-based
practice requires that the best available information
or evidence is integrated with clinical experiences
and expertise and with due consideration of the
clients’ priorities and preferences (Sackett, 2000;
Turpin & Higgs, 2009). It is therefore important that
therapists review the nature of evidence they are
accessing and consider its dependability and generalizability carefully in light of their own experience
and expertise and the priorities and preferences of
their clients.
There are various types of evidence, including the
following:
Ô Anecdotal material (e.g., home modification
listservs)
Ô Expert opinion or theoretical/unsystematic literature reviews or standards
Ô Case (i.e., case series and case comparative)
Ô Observational (i.e., cohort studies, pre- and
post-test studies, and cross-sectional and longitudinal studies)
Ô Quasi-experimental (i.e., no randomization)
Ô Randomized controlled trial (RCT)
Ô Systematic review (Bridge & Phibbs, 2003)
Each of these types of evidence provides a different type of information, which varies in terms
of its applicability to specific situations, level of
dependability, and ability to demonstrate the benefits of a particular intervention (Turpin & Higgs,
2009). Anecdotal information and expert opinion
can be based on accumulated experience and often
provides the detailed and practical information
required when considering specific situations and
local products and designs. Therapists should be
aware, however, that these sources are prone to
bias; the information is likely to be shaped by personal preferences and unique experiences. Similarly,
case-based, observational, and quasi-experimental
studies can provide detailed information about interventions, the contexts in which they have been
applied, and the changes that resulted from these.
It is important to note, however, that the observed
changes might also be attributable to other variables that have not been controlled for. RCTs and
systematic reviews provide dependable information
about the outcomes of interventions because they
are structured to control for confounding variables
and to minimize potential bias. For example, a 2011
RCT reviewed the effectiveness of an environmental
assessment and modification intervention in the prevention of falls in older people (Pighills, Torgerson,
Sheldon, Drummond, & Bland, 2011). However, to
date, these types of studies have tended to examine
the impact of home modifications generally and in
combination with a range of other interventions, and
research on specific home modification interventions and their relative impact in a variety of situations is limited. Table 10-1 reviews the advantages
and disadvantages of various types of evidence as
described by Bridge and Phibbs (2003).
Although applied research comparing the effectiveness of various environmental interventions for
populations is limited, research on home modifications is increasing (Box 10-1 includes current
evidence on grab bars). Literature about many traditional occupational therapy interventions is in the
category of health; however, home modification and
related literature can also be found in other fields
of study, such as social sciences and architecture.
Chapter 14 provides more detailed information on
home modifications research.
Sourcing and Evaluating Products and Designs
233
Table 10-1. Advantages and Disadvantages of Various Types of Evidence
TYPE OF
EVIDENCE
ADVANTAGES
DISADVANTAGES
Anecdotal material
• May assist in reconceptualization of problem
area
• May add to knowledge in terms of scoping
variables or measurement methods
• May be based on hearsay
• May not clearly indicate assumptions or
method
• May be faulty or inaccurate
Expert opinion/
theoretical/
unsystematic literature
review/standards
• May assist in reconceptualization of problem
area
• May add to knowledge in terms of scoping
variables or measurement methods
• May be based on hearsay
• May not clearly indicate assumptions or
method
• May be faulty or inaccurate
Case (i.e., case
series and case
comparative)
• May generate hypotheses
• Less expensive than other research designs
• Can have large sample sizes
• No statistical validity
• Hard to control for confounders as no
controls
• Subject to recall bias as retrospective
• Difficult to demonstrate causality
Observational (i.e.,
cohort studies, preand posttest studies,
cross-sectional and
longitudinal studies)
• Most reliable observational data are cohort
studies because there is no recall bias and
can ensure baseline similarities between
groups
• More reliable answers and less statistical
problems than case control
• Can take a long time
• Can be an expensive, large-scale
undertaking
• Useful when randomized studies are
inappropriate
• External factors can change over time
with panel or longitudinal data
Quasi-experimental
(i.e., no
randomization)
• Remains experimenter controlled
• Most reliable when variables of interest and
controls for these made explicit
• Because variables not fully controlled
may exhibit selection, performance, and
measurement bias
RCT
• Provides evidence with causality
• Considered “gold standard” in health research
• Random allocation balances known, unknown,
and unmeasurable confounding variables
• Greater confidence that conclusions are
attributable solely to intervention manipulation
• Reduces selection bias
• Blinding reduces measurement and
performance bias
• Provides evidence of causality
• Assumes variables can be controlled
and groups appropriately matched
• Assumes randomized blind allocation of
intervention is given ethical clearance
by relevant human ethics review board
• Very expensive in terms of time and
money
• May be compliance and participant
attrition problems
• Blinding and random allocation can be
problematic
Systematic review
• Attempts to answer a particular research
question in an evidence-based manner
• Provides policymakers with a summary of
available evidence
• Effectively maps the inputs and outcomes
under review
• Cutoffs for inclusion may be too high or
too low
• Question under consideration may not
be specified properly (i.e., it may be
too broad or too specific)
• Results capture a snapshot of published
research at a particular time interval so
results must be interpreted in relation to
currency of information and change in
the body of knowledge being reviewed
Reprinted with permission from Bridge, C., & Phibbs, P. (2003). Protocol guidelines for systematic reviews of home modification information
to inform best practice. Sydney, Australia: Home Modification Information Clearinghouse, University of New South Wales (UNSW): Sydney.
Retrieved from https://www.homemods.info/about/administrative-publications/protocol-guidelines-for-systematic-reviews-of-home-modificationinformation-to-inform-best-practice#main-content. Table 4: Study design definitions.
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Box 10-1. Grab Bars—Current Evidence
Grab bars are commonly installed to compensate for age-related deficits (impaired balance, range of motion, strength,
and endurance) and to enable safe and independent transfers on and off toilets and in and out of baths and showers
(Axtell & Yausda, 1993; Struyk & Katsura, 1988; Tideiksaar, 1997). Evidence is emerging that they may assist in preventing
falls (Sattin, Rodriguez, DeVito, & Wingo, 1998). They are a common fitting in people’s homes with seniors installing two
grab bars on average, (Clemson & Martin, 1996; Plautz, Beck, Selmar, & Radersky, 1996). Although some studies report
that community-dwelling individuals commonly own grab bars (Parker & Thorslund, 1991; Sonn & Grimby, 1994; Trickey,
Maltais, Gosselin, & Robitaille, 1993), others suggest that they may not always use them. In one study, only one participant
reported using the grab bars present at the time of the fall; most participants did not use grab bars because the grab bars felt
awkward or unsafe to use (Aminzadeh, Edwards, Lockett, & Nair, 2000). Such findings highlight the need for occupational
therapists to be careful about grab bar recommendations in relation to other options such as equipment.
WHICH CONFIGURATION IS BEST?
Multiple grab bar configurations may be used by people who present with a diverse range of health conditions or
disabilities (Kennedy, Arcelus, Guitard, Goubran, & Sveistrup, 2015). It is important to use clinical reasoning to determine
the most appropriate configuration of grab bar. Current literature discusses a range of options for positioning of grab bars
including, for example, options for people who are seated on toilets and who engage in sit-to-stand transfers. These ideas
include:
• Positioning the horizontal grab bar 4 cm above the person’s greater trochanter when he or she is in the seated
position (Bridge, 2003; McDonald, 1997; McDonald, Bridge, & Smith, 1996; Ongley, 1999; Roland, 1996). This
recommendation needs to be treated with caution as a small sample size was used in the original research and the
findings cannot be generalized
• Positioning the shoulder at 90 degrees flexion and elbow at 150 to 180 degrees flexion to determine the location of
the grab bar (Woodson, 1981). This recommendation needs to be treated with caution as not all people like to pull
on a grab bar when moving from sitting to standing.
• Aligning the grab bar on the nonaffected side of body (O’Meara & Smith, 2006)
Other research indicates the following findings:
• Vertical grab bars are suited to stage 1 and 4 of sit-to-stand transfers (Chan, Laporte, & Sveistrup, 1999; Laporte,
Chan, & Sveistrup, 1999); they require a pull-up action; they reduce total range of motion at hip, hip extension
torque, movement needed at knees; they reduce perceived pain levels; and higher rails reduce biomechanical load.
• Angled grab bars suit stages 1 and 4 of the sit-to-stand transfers and allow for flexible hand placement as the person
moves (Chan et al., 1999; Laporte et al., 1999).
• Horizontal grab bars require a push-up action, assist weightbearing, and support the forearm, but if they are too
high or too low, they will not assist momentum and postural stability; they also require larger forces and kinetic and
kinematic outcomes observed (Bridge, 2003; O’Meara & Smith, 2002, 2005, 2006)
• Unilateral grab bars
» Suit stages 2 and 3 of sit-to-stand transfers (Chan et al., 1999; Laporte et al., 1999)
» Suit people with lower limb weakness and asymmetrical conditions
» Need to be placed ipsilateral for hip and ankle conditions or contralateral for knee joint problems (O’Meara, 2003)
• Bilateral grab bars
» Suit people with kyphosis, lordosis, back pain
» Ensure symmetry of body position, the alignment of center of mass and center of pressure (Chan et al., 1999;
Laporte et al., 1999)
» Allow the alternating of hands and bilateral hand use (e.g., when someone needs to stand to adjust his or her clothes)
Most international access standards for countries such as the United States, Canada, and Australia recommend
multidirection rails in public bathrooms. Occupational therapists are choosing to use this information to guide their practice
and some nongovernment and government organizations are making it mandatory for their services to install grab bars
to match this information in domestic homes rather than tailor the installation to suit the clinical requirements of the person
(refer to Chapter 4 for a discussion about the relevance and intent of access standards for home modification work).
(continued)
Sourcing and Evaluating Products and Designs
235
Box 10-1. Grab Bars—Current Evidence (continued)
Sanford, Arch, and Megrew (1995) found that toilet grab bar configurations preferred by most nonambulatory older
adults did not comply with either American or Canadian building code regulations (Kennedy et al., 2015). Sanford and
Bosch (2013) also compared an American With Disabilities Act Accessibility Guidelines (ADAAG)–compliant design with
alternative designs for people needing assisted toileting. The ADAAG is a set of prescriptive requirements for accessible
design in public facilities. Findings indicated that caregivers preferred the largest of the tested configurations, where there
were two fold-down grab bars provided and the center line of the toilet was 30 in from the sidewall rather than the 18 in
required by the ADAAG.
Caregivers perceived the grab bar locations as better for helping them safely transfer subjects in a modified (non-ADAAG)
configuration, and also that the grab bar style in a modified (non-ADAAG) configuration improved safety when transferring
subjects. Although not statistically significant, there was a general downward trend in the number of incidents with the folddown grab bars compared to the side-mounted grab bar, and fewer incidents associated with an increase in the amount
of space provided adjacent to the toilet.
These international access standards can provide some helpful information to guide grab bar recommendations (such
as detail on how to describe, measure, and draw grab bars in different environments), but they should not be used as
the starting point for clinical reasoning. Occupational therapists need to be mindful that the grab bar configurations for
ambulant or wheelchair users may not suit the specific needs of their clients. For example, this is particularly relevant if
clients are of short stature, have shoulder pain or limited reach and grasp, are in the bariatric range, and/or take pain
medication affecting their toileting. Further, the home environment may not have a shower or toilet configuration matching
those described in the access standards for the location of the grab bar. Equipment that is not described in the access
standards (such as mobile shower commodes) and the presence of a carer with their specific access requirements also
need to be considered when determining the best grab bar product and location.
WARNING!
There are specific situations where grab bars should not be installed. For example, occupational therapists need to check
with design and construction professionals about whether it is appropriate to install any type of grab bar that may pierce
the waterproof lining on the bathroom floor. This may include grab bars that are swing-away (mounted to a post that
fastens to the floor), wall-to-floor, or floor-to-ceiling grab bars. Occupational therapists should not encourage clients to use
suction rails as these are not designed for weightbearing. Similarly, if builders wish to use toggle bolts to fasten rails to
walls rather than securing them into studs, the grab bars may not hold on the wall, depending on the thickness of the wall
material and the weight placed on the grab bar by the user.
The following databases can be useful for locating
literature on home modifications and environmental
design:
Ô Health-related databases: Pubmed (www.ncbi.
nlm.nih.gov/pubmed/), OTseeker (www.otseeker.com), OTDbase (www.otdbase.org), and
Cinahl (https://health.ebsco.com/products/
the-cinahl-database)
Ô Social-sciences databases: Social Services
Abstracts, Sociological Abstracts, and Ageline
(aging-related information in psychological,
health-related, social, economics, public policy,
and the health sciences)
Ô Architectural databases: The Avery Index to
Architectural Periodicals, and Architectural
Publications Index
These databases access literature on theoretical frameworks, literature reviews, and research
published in refereed journals and can be searched
using keywords or broad search terms. In areas
of practice with vast quantities of research, it can
be useful to confine searches using specific terms
related to the problem, intervention, client group,
and outcome (PICO). For example, if searching for
research on grab bars to assist older people into
and out of the bath, the search would be defined as
follows:
Ô P—Problem: Getting in and out of the bath
Ô I—Intervention: Grab bar
Ô C—Client group: Older people
Ô O—Outcome: Increased safety and independence
Other terms would also need to be included in
the search to ensure that all relevant literature was
identified. For example, the bath might be referred
to in some studies as a tub; older people are also
referred to as elders; grab bars are called grab rails
in some countries; and some studies might also
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identify outcomes as reduced falls or hospitalizations.
It is useful to seek the assistance of a librarian when
developing a list of search terms because they are
aware of alternative terms and terms used in different databases, such as the Medical Subject Headings
terms. Some databases also provide advanced
search strategies that allow the user to define the
age range of the subjects and nature of the studies
(e.g., RCTs).
Using specific PICO search terms assists in narrowing the search to the most relevant studies; however, targeted research is limited in many areas of
occupational therapy practice. In home modification
practice, it is advisable to use broad terms to ensure
that all relevant literature is located.
Systematic reviews of research can be located
in the Cochrane Collaboration (www.cochrane.org/
reviews). Cochrane reviews examine the evidence
for and against the appropriateness and effectiveness of a range of interventions in specific circumstances based on the best available information. For
example, reviews have examined the impact of home
modifications on the reduction of injuries (Lyons et
al., 2006) and interventions for preventing falls in
older people (Gillespie et al., 2009).
The Home Modification Information Clearing
House (www.homemods.info) is also a valuable
resource, providing evidence-based reviews on a
range of home modification-related interventions,
such as coatings for tiled floors (Whitfield, Bridge,
& Mathews, 2005), designing home environments for
people who experience problems with cognition and
who display aggressive or self-injurious behavior
(Hodges, Bridge, Donelly, & Chaudhary, 2007), and
selecting diameters for grab bars (Oram, Cameron,
& Bridge, 2006).
Additionally, the genHOME project (https://www.
rcot.co.uk/about-us/specialist-sections/housingrcot-ss/genhome) is a collaboration between academics, practitioners, researchers and members
of the public supported by the Royal College of
Occupational Therapists, United Kingdom (RCOT),
which seeks to raise the quality and impact of
research related to housing design and home modifications (RCOT, 2017). This project aims to achieve
this goal by identifying research priorities, building
evidence, facilitating interdisciplinary research, promoting efficient use of research resources, influencing policy and legislation, and providing a means for
creating and sharing information between health
professionals (RCOT, 2017).
There is also a wealth of information of relevance
to home modification practice in legislative and
regulatory documents and on the internet and, in
particular, on websites and social media dedicated
to home design and modification, and in the grey literature such as non-refereed publications posted on
the internet, social media sites, industry newsletters,
and manufacturers’ specifications (Bridge & Phibbs,
2003). It is important that therapists carefully evaluate information for its relevance, dependability, and
generalizability and consider their own experience
and expertise and the priorities and preferences of
their clients before applying it in practice.
Conformity With Standards, Guidelines, and
Codes
Legislative and regulatory documents are particularly important when selecting and designing environmental interventions and evaluating the suitability of various options. Many products and designs
are governed by design and installation requirements detailed in various standards, guidelines,
and codes. Therapists need to be aware of these
documents and ensure that proposed products or
designs meet the appropriate requirements of their
region or country.
The three national standards that guide the accessible design of buildings in the United States are the
following:
1. Americans With Disabilities Act and
Architectural Barriers Act (ADA-ABA)
Accessibility Guidelines (United States Access
Board, 2004/2014)
2. The Fair Housing Accessibility Guidelines
(U.S. Department of Housing and Urban
Development, 1990)
3. American National Standards Institute [ANSI]
ICC A117.1-2009—Accessible and Usable
Buildings and Facilities (ANSI, 2010)
Because the specifications in these standards
relate specifically to the design of public buildings
and multifamily dwellings and units, they do not
apply directly to the design of single-family houses,
except where elements are included in local building
codes. Model building codes that serve as a basis
for local codes might include accessibility requirements for specific building projects within their
jurisdiction.
Elements of these standards can sometimes be
used in the design of new homes or the modification
of existing homes to promote access and mobility
within the dwelling. Designers can depart from technical and scoping requirements in these guidelines
when they can demonstrate that alternative designs
and technologies can provide equivalent or greater
access to, and usability of, the facility. In addition,
variations to the specifications detailed in building
standards are often required in residential settings
Sourcing and Evaluating Products and Designs
when residents have particular requirements or
when design is limited by existing topography of the
land, building structures, service systems, and space
restrictions.
There are several design elements specified in
these standards, which include the following:
Ô Dimensions (e.g., the height, width, depth of
clearances and spaces, and size and location of
various fixtures and fittings)
Ô Features of fixtures and fittings (e.g., level
handles on doors and drawers or taps)
Ô Structural and technical requirements (e.g.,
sheer forces, maximum slope, maximum length
of ramps, minimum height of edgings, minimum
space between rail and wall)
Ô Materials and finishes (e.g., the nature of surfaces and edges)
Dimensions and the features of fixtures and fittings detailed in these accessibility standards allow
adults with disabilities to function in buildings. The
standards are designed to ensure adult wheelchair
users can independently move into and through the
structure and use various controls. These specifications provide a useful reference when designing
modifications for individuals similar in stature, size,
and functional ability who are using similar assistive
technologies to those for whom the standards were
designed. However, many young clients with multiple and severe impairments and older clients with
comorbidities and secondary conditions do not fit
this profile and require dimensions and features to
be tailored to their specific requirements (Sanford,
2012; Steinfeld & Shea, 1993). Additionally, it is
important that therapists are aware that many standards are based on research from past periods and
that changes in user demographics and advances
in technology can and will likely impact on the suitability for applying standards to specific situations
or client circumstances in current times (Steinfield,
Maisel, Feathers, & D’Souza, 2010).
Therapists are often well placed to assist in customizing designs to the specific requirements of an
individual because they can determine the circulation space each person requires to move throughout
the home and maneuver in various areas. They are
also able to measure each individual and his or her
equipment to determine the best location for various
fixtures and fittings. Therapists’ understanding of
function and occupational performance allows them
to define and identify design features that promote
better performance. In addition, their observations
of daily routines assist them in understanding how
spaces and controls are used and when and where
people are provided with assistance. Because most
237
standards do not consider the requirements of people who rely on assistance (Sanford, 2012), dimensions detailed in these documents often need to be
modified to accommodate the spatial requirements
of caregivers during tasks and the equipment they
might use in their routine with the client.
The structural and technical specifications in
the standards ensure the safety of people using the
building. Engineering evaluations have determined
the structural strength requirements of fixtures and
fittings, such as grab bars, tub and shower seats,
fasteners, and mounting devices, under regular use
by people within the average weight range. It is inadvisable to select products or design modifications
that do not meet these requirements without the
advice of an engineer or suitably qualified consultant. Therapists should check that products have
been certified as meeting these specifications and
that contractors are aware of the requirements when
installing these fixtures and fittings. Promotional
materials produced by suppliers that make a general statement that their products meet accessibility standards are not sufficient proof. Therapists
should seek supporting documentation and ensure
that the product meets all the specifications. For
example, some products might meet the requirements in terms of dimensions but may not meet, or
only partially meet, the structural strength requirements. In the ADA-ABA, specifications relating to the
structural strength of shower “compartment” seats
state that “allowable stresses shall not be exceeded
for materials used where a vertical or horizontal
force of 250 pounds (1,112 Newton) is applied at any
point on the seat, fastener mounting device, or supporting structure” (ANSI, 2010, p. 62). For example,
therapists would want to ensure that shower seats
under consideration are able to substantiate their
claims for meeting both the vertical and horizontal force requirements. Further, therapists working
with people who are outside of the average weight
range would need to select products that have been
designed to withstand the additional forces to which
they are likely to be subjected.
It is particularly important that any imported
products meet the legislative building requirements
of the country where they are to be installed. For
example, many grab bars made in the United States
designed to meet the ADA-ABA would withstand a
lateral load of 250 pounds (1,112 Newton). However,
these would not meet the requirements set out in
Australia where the accessibility standards require
grab bars to withstand 1,100 Newton in all directions.
It is important that therapists are aware of the specific building and plumbing legislation for the area(s)
in which they are making recommendations as these
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are often region specific and variations between
regions are not uncommon. For example, slip resistant surfaces must be provided on any ramp or set of
stairs as per the requirements of building legislation
in specific countries. Further, some legislation refers
to access standards for large external modifications
that must be installed in domestic homes, but others
do not.
Regarding access standards, the gradient or slope
and maximum height and length of ramps detailed
in these documents have been determined as being
functionally appropriate for most adults with disabilities (Sanford, Story, & Jones, 1997). It is therefore
advisable to design ramps to these requirements
unless it is determined that the client or the attendant is unable to manage a ramp with these specifications. In these situations, therapists can recommend
that the ramp be designed to specifications greater
than the minimum required by the standards if this
is practicable in the environment and if there is no
legislative requirement to comply with the standard.
In some situations, the ramp might need to be made
steeper or the length shortened due to environmental constraints. In these situations, the therapist
would need to demonstrate that the client has the
capacity to traverse a steeper or shorter ramp and
provide justification for deviating from the standard
(Canada Mortgage and Housing Corporation, 2005,
2016). Support for varying from the standard might
include a description of the existing environmental
limitations, a statement of intended usage and potential users, and a report on the user’s performance
when trialing a ramp of the proposed gradient, or
research evidence on the effect of ramp slope on
performance, such as that undertaken by Sanford
and colleagues (1997). Though it is reasonable to
tailor an environmental intervention to the specific
needs of the current resident, therapists should also
be mindful of the person’s long-term capacities,
visitors to the property, and future residents when
designing permanent modifications and the requirements of their local authorities with respect to
installing modifications that comply with local or
state/provincial planning laws.
Design elements, such as the presence and height
of edging to ramps or the space between grab bars
or handrails and the adjacent wall, also improve
people’s safety and promote effective use of the built
environment. It is important that these elements or
suitable alternatives are reflected in product choices
and are incorporated into the design of modifications. Materials and finishes might also have safety
and/or functional implications; for example, insulating exposed pipes or removing sharp and abrasive
surfaces under sinks or recommending ceramic
shrouds covering the pipework ensures that wheelchair users’ knees and thighs are not injured when
they wheel under sinks. Grab bars that rotate in
their fittings can also be hazardous to users. The
recommended level of slip resistance for walkways
and ramps is also an important consideration when
designing modifications for the home environment
to ensure the safety of householders walking or
wheeling on the surface.
By understanding the specifications in the accessibility standards and their intent, therapists can
ensure that elements relating to safety are incorporated into the design of modifications. However,
where a client’s age, stature, size, functional abilities
and equipment type, and dimensions lie outside of
those covered by the standards, the dimensions and
functional elements of the product and design should
be reviewed considering the functional requirements of each individual. Therapists also need to
be mindful that there are many standards governing
the design of domestic dwellings that need to be
adhered to when redesigning areas of the home, and
they will need to liaise closely with designers and
building professionals to ensure that designs and
products conform to these. In some instances, these
standards might impede the design of accessible features, resulting in therapists having to work closely
with building and design professionals to negotiate
a mutually acceptable outcome if possible. Further
information on these is provided in Chapter 11.
Evolution of Design and Good Design Practice
Over time, the thinking and approaches to design
have changed in response to population changes and
the recognition of the rights of all people in society
(Persson, Ahman, Yngling, & Gulliksen, 2015). This
has resulted in an evolution of design and building
practice (Figure 10-1; Ainsworth & de Jonge, 2008).
With the population aging, the associated influence
on rates of disability, and many people’s desire to
remain living independently as long as possible,
there is an increased need for housing design that
accommodates the needs of all people over the lifespan (Smith, Rayer, & Smith, 2008).
Initially, the design approach used for people with
specific housing needs was purpose-built design.
This approach, design, and building practice centered on the specific conditions and needs of the
individual for whom the design was primarily for.
This saw the inclusion and consideration of specialized equipment and products that were necessary
to support the individual’s function, particularly
in activities of basic self-care. In this first stage of
evolution, the environment was a prosthetic and the
features of the design and associated modifications
Sourcing and Evaluating Products and Designs
239
Figure 10-1. Evolution of design and building practice (Ainsworth & de Jonge, 2008).
were fixed in place and noticeable. To this end,
homes and modifications were designed to meet the
specific needs of individuals and the emphasis was
on designing and modifying to enable and improve
the access for people using wheelchairs. To achieve
purpose-built design, occupational therapists would
often assess the individual’s function and make the
relevant recommendations and suggestions for modification, which would be summarized into reports
for architects to interpret and design. This approach
perpetuated people with disabilities being defined
in terms of their dysfunction (e.g., “a paraplegic” and
as being “sick” and dependent on care). It provided a
fragmented view of the person and offered little recognition of the person’s needs beyond that of basic
self-care (Ainsworth & de Jonge, 2008).
Purpose-built design was followed by accessible
design. This stage of evolution was primarily focused
on design features for access and mobility associated
with public buildings and meeting the requirements
of the relevant standards. In many countries, accessible design standards were established and these
formed the foundation for many recommendations
for home modification and design for people with
disabilities (see Chapter 11 for a detailed description of the development, benefits, and limitations
of accessible design standards). Access standards
were established using a generalized view of the
needs of the population of people with disabilities
and were based on the capabilities of young people
who mobilize independently in standard manual or
electric wheelchairs. To this end, clearances, circulation spaces, and reach zones in the home were
based on dated and restricted data and the associated specifications. Accessible design stresses the
application of minimum standards to design and
modification while maintaining the consideration of
client specific needs, with emphasis on designing for
wheelchair access. It incorporated and considered
the spatial requirements and dimensions of the base
building; however, design and modifications solutions were often prescriptive and lacked creativity
and the fixtures often continued to be permanently
fixed and noticeable. This often resulted in home
designs and modifications that were clinical, oversized, and inelegant. This approach to design continued to view the person in terms of their functional
ability, dimensions (anthropometrics), and how they
fit the relevant standards. The emphasis remained
on activities of daily living, extending beyond that
of just basic self-care to include mobility and access
within and around the home, however, did not consider the person’s roles in the home or community.
The needs of the individual were interpreted by
the occupational therapist and were communicated
through and between professionals, often with little
input from the client, which created and reinforced
an information gap between people with disabilities
and the industry (Ainsworth & de Jonge, 2008).
Both purpose-built design and accessible design
were more traditional approaches to design and
modifications that originated from the medical
model of disability. In these approaches, therapists
focused on achieving independence using alternative strategies and devices designed within a medical context. Many of these are made of metal and
plastic with cold, hard surfaces and have a clinical
appearance. Similarly, early home modifications
tended to have an institutional appearance (Sanford
& Butterfield, 2005). Such devices and modifications
often do not fit well with the ambience of a home
environment where soft surfaces and warm colors
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often predominate. Further, when the appearance of
devices and modifications provoke strong negative
reactions from the user and visitors to the home, it
can influence acceptance and use (Aplin et al., 2013;
Hocking, 1999; Wessels, Dijcks, Soede, Gelderblom, &
De Witte, 2003; Wielandt & Strong, 2000).
After these more traditional approaches came
adaptable design (referred to as lifetime homes in
some countries). This stage in evolution offered
greater choice, flexibility, and market appeal than
its predecessors, while maintaining previous consideration of accessible features including clearances, circulation spaces, and reach zones. Adaptable
design demonstrated an appreciation of diversity
of function across the lifespan. People were seen
to have a variety of needs and to interact with
the social and physical environment. Additionally,
there was an increased recognition of the person’s
role in the home and community and their need
to be able to access and socialize with friends and
family. These led to an improved understanding of
the intent of design elements, enabling more creativity in approaches to design and modifications.
Furthermore, the traditional focus on one individual
shifted and designs and modifications were developed to suit a range of individuals and could often
be adjusted to be fully accessible with adjustments
frequently possible using unskilled labor. This stage
of evolution resulted in designs and modifications
in homes that remained centered on access requirements, but also included:
Ô All essential elements and some desirable
elements
Ô Enhanced measurements and additional residential features
Ô Space for carers, security, and color contrast
(Ainsworth & de Jonge, 2008)
To this end, while some public design elements
persisted (e.g. large open bathrooms), designs and
modifications usually made good design sense and
had an increased focus on safety, climate, aesthetics, flow, and affordability (Ainsworth & de Jonge,
2008). This resulted in environments appearing less
institutional and the solutions being more elegant
overall (Ainsworth & de Jonge, 2008). The designs
and modifications of this design approach created
housing that provided greater choice for people with
a variety of abilities and that was useable across the
life span (Ainsworth & de Jonge, 2008). This enabled
people to age in place, remain in the community,
and maintain natural support networks (Balandin &
Chapman, 2001).
With the emergence of universal design (UD)
there has been an increased emphasis on designing
products, environments, and systems for the broader community rather than designing specifically
for people with disabilities or special requirements
(Connell and Sanford, 1999). UD recognizes the
diversity of capabilities of users (Wylde, 1995) and
aims to make products, environments, and systems
inclusive, spanning age, gender, and ability while
reducing the need for accommodations and specialized assistive devices (The Center for Universal
Design, 1997; Steinfeld & Maisel, 2012). It does not,
however, remove the need for standards that outline
the legal limits for minimum accessibility (Steinfeld
& Maisel, 2012).
Traditionally, UD has been defined as “the design
of products and environments to be usable by all
people, to the greatest extent possible, without the
need for specialized design” (Mace, 1985 p. 147; RL
Mace Universal Design Institute, 2017).
However, due to concerns regarding specificity and impracticality, further terms and definitions
have been posited, including:
Design for All—design for human diversity,
social inclusion, and equality. Design for
All aims to enable all people to have equal
opportunities to participate in every aspect
of society. To achieve this, the built environment, everyday objects, services, culture
and information—in short, everything that
is designed and made by people to be used
by people—must be accessible, convenient
for everyone in society to use and responsive to evolving human diversity (European
Institute for Design and Disability, 2004)
and, more recently,
Universal design is a process that enables
and empowers a diverse population by
improving human performance, health and
wellness, and social participation. (Steinfeld
& Maisel, 2012, p. 29)
Despite the evolution of the terms and definitions,
consensus is yet to be established on the specifics
of a definition. It is clear, however, that benefit to
the broader community and inclusion are common
themes (Steinfeld & Maisel, 2012).
This approach to design required a fundamental
shift in thinking from previous stages of evolution
(i.e., progressing from removing environmental barriers to designing to ensure inclusion of all people
to the greatest possible extent, regardless of age or
ability; Ainsworth & de Jonge, 2008). It addresses
the design of products, buildings and information
system and requires:
Ô An understanding of the broad range of human
abilities
Sourcing and Evaluating Products and Designs
Ô An appreciation of changes that occur across
the lifespan
Ô A creative approach to design
Ô Consideration of shape, adjustability, and placement of features
However, if successfully achieved, it promotes
social mobility and integration for persons of all
abilities (Ainsworth & de Jonge, 2008). This allows
all people, regardless of ability, to be part of society
and ensures that people with disabilities or special
requirements are no longer viewed as being different. UD provides a range of choices that enables
designs and products to be elegant and suitable
for the home environment while promoting safety
and ease of use for everyone living in or visiting the
home (Ainsworth & de Jonge, 2008). Further, attention to the design ensures that modifications continue to be useful as the needs of clients and other
householders change over time without the need to
modify the product or design. Universally designed
products and environments have also been found to
be considered more functional, accessible, safe, and
attractive by users and less visible than specialized
options (Park, 2006). Moreover, while there are often
additional immediate costs for designs, products,
and systems, there are frequently persisting cost
benefits in the long term (Ainsworth & de Jonge,
2008).
When examining universally designed products
and environments, it is noted that like the definition
of UD, there has been a variety of descriptions proposed over time. These descriptions have also often
guided the development of subsequent methods of
UD evaluation in clinical practice.
One such description was outlined by Wylde
(1995), who described universally designed products and environments as being:
Ô Usable and useful: Can be used successfully
to perform the intended function simply and
expediently
241
Ô Accessible, adaptable, and adjustable:
Accessible to individuals of varying abilities
and designed to be adjusted or adapted for
those whose abilities fall beyond the ranges of
practical design considerations
Ô Logical: Built purposefully with each component and feature, and placement and function
consistent with expectations
This set of descriptors forms the basis for the
Enabling Products Sourcebook 2 (Wylde, 1995), which
provides a “head-to-toe” evaluation of products
using the following criteria:
Ô The head: Cognition, vision, audition, and
olfaction
Ô The upper body: Manual dexterity
Ô The lower body: Strength and stamina
Ô Overall safety features
Ô Product features related to cleaning and
maintenance
While not every criterion will be relevant to every
product, the criteria assist in evaluating the range of
users who will be able to use the product effectively
(Wylde, 1995). For example, when reviewing the
visual demands of a product, Wylde (1995) examines
whether:
Ô Functions with a visual output are accompanied by audible and/or tactile output
Ô The surface of the product has a non-glare finish in areas where vision is required
Ô All graphics, signage, and coding are legible
under adverse viewing conditions
Ô The print and symbols provide color contrasting with the background
Ô Use of colors as indicators is purposeful and
visible
Ô Indicator lights relate directly to the function
they control
Ô Neutral: Do not demand right- or left-handed
performance
Ô An integral light source is provided where
vision is required for safe operation
Ô Inclusive: Built to include a diverse population
of users (i.e., of differing sizes and abilities)
Ô Raised lettering is used where possible
Ô Visible: Provide clear, visible clues as to how
they are to be used
Ô Elegant: Are aesthetically pleasing
Ô Redundant: Provide additional cues to the user
(e.g., acoustic, tactile, and visual information)
Ô Simple: Avoid superfluous controls, ornamentation, and embellishments
Ô Where audible and tactile cues are not feasible,
the product accommodates Braille overlays on
functions requiring vision
Despite the presence of other descriptions, such
as that of Wylde (1995), the most well-known and
possibly popular description is that of the Seven
Principles of Universal Design proposed by The
Center for Universal Design (1997). These principles were developed to promote products and
242
Chapter 10
Figure 10-2. Universal Design Performance Measures for Products. (Reprinted with permission from Center for Universal Design.
[2000]. Evaluating the universal design performance of products. Raleigh, NC: The Center for Universal Design, North Carolina State
University. Retrieved from https://www.ncsu.edu/ncsu/design/cud/pubs_p/docs/UDPMD.pdf)
environments consistent with the original definition
of UD, provided on page 242.
The principles encourage designers to develop
products and environments that allow the following:
Ô Equitable use: Useful and marketable to people
with diverse abilities
Ô Flexibility in use: Accommodates a wide range
of individual preferences and abilities
Ô Simple and intuitive use: Easy to understand,
regardless of the user’s experience, knowledge,
language skills, or current concentration level
Ô Perceptible information: Communicates necessary information effectively to the user, regardless of ambient conditions or the user’s sensory
abilities
Ô Tolerance for error: Minimizes hazards and the
adverse consequences of accidental or unintended actions
Ô Low physical effort: Can be used efficiently and
comfortably and with a minimum of fatigue
Ô Size and space for approach and use: Appropriate
size and space for approach, reach, manipulation, and use regardless of user’s body size,
posture, or mobility (The Center for Universal
Design, 1997)
Further to the principles, The Center for Universal
Design (2000) also developed the Universal Design
Performance Measure (Figure 10-2), which designers
and therapists can use to evaluate the design characteristics of options and compare the universality
of various products and designs being considered
in home modification practice. The measure is not
intended to replace user evaluation or experience
with a product or design but assists therapists and
designers in evaluating the broader usability of
interventions.
Although these principles appear to be simple,
people vary enormously in terms of height, weight,
endurance, strength, balance, mobility, and visual
and hearing acuity (Conway, 2008). When considering the suitability of design, therapists need to draw
Sourcing and Evaluating Products and Designs
on their understanding of this diversity and aim to
maximize the usability of the product and environment for as many people as possible while ensuring
that they continue to support clients’ occupational
performance. To this end, it is vital that therapists
have a comprehensive understanding of diversity
to enable them to design universally. As a profession, occupational therapy encourages its members
to develop and consistently expand upon their
knowledge of diversity, and this can be invaluable in
reviewing the potential of product and design solutions. Furthermore, this expertise allows therapists
to make a significant contribution to the development of products and designs. Notwithstanding the
well-intentioned nature and the benefits of UD, this
approach does continue to experience challenges to
successful implementation. Some of these include:
Ô Confusion with accessibility using a “template”
approach
243
Ô Overemphasis on physical aspects (Calkins,
Sanford, & Proffitt, 2001)
the others previously mentioned, one primary difference is the presence of the phrase “reasonably
possible” (Persson et al., 2015). The presence of
this phrase has been criticized in the literature as
possibly impeding the rights of inclusion of people
with disabilities, contrary to documentation, such
as the United Nations’ Convention on the Rights of
Persons With Disabilities, if it is too costly or difficult (Persson et al., 2015). However, this approach
to design aims to give greater acknowledgement to
the existing diversity in the population, identifying that it is not always feasible or appropriate to
design one product that meets the needs of the
entire population (University of Cambridge, 2017a).
It proposes that every decision related to design has
the potential to include or exclude people and highlights the necessity for understanding diversity to
make informed decisions to include as many people
as possible (University of Cambridge, 2017a). To
respond to diversity in the population, this approach
directs design through:
Ô “Developing a family of products and derivatives to provide the best possible coverage of
the population
Ô Lack of understanding of sensory, cognitive,
psychological, and social diversity
Ô Ensuring that each individual product has clear
and distinct target users
Ô The perception that UD restricts creativity and
employs a “one size fits all” approach (e.g., a
“McDesign” approach; Ainsworth & de Jonge,
2008; Sanford, 2012)
Ô Reducing the level of ability required to use
each product, in order to improve the user
experience for a broad range of customers, in a
variety of situations” (University of Cambridge,
2017a)
Furthermore, this approach, while not outlining a
specific set of criteria, does offer a more pragmatic
approach to acknowledging and responding to diversity as it offers an actionable process for decision
making at the concept stage of design development.
This process includes the following four phases:
1. Manage: Review the evidence to decide “What
should we do next?”
Ô Association with disability design (Maisel,
2005)
Ô Concern about additional immediate costs
Ô Principles that are incomplete, complex, and
ambiguous (Steinfeld, 2006).
However, of the challenges that exist, probably
the most noteworthy is the absence of consensus
on the definition. This challenge has seen the creation of terminology, often used interchangeably,
which has been created in a similar fashion but in
different areas of the world (Persson et al., 2015;
The Norwegian Centre for Design and Architecture,
2010). While some of these terminologies, associated
definitions, and accompanying concepts are very
similar (e.g., UD and Design for All), there is another:
inclusive design, evolved from product design rather
than design of the built environment, which offers
a slightly different focus (University of Cambridge,
2017a).
Inclusive design has been defined as “the design of
mainstream products and/or services that are accessible to, and usable by, as many people as reasonably
possible … without the need for special adaptation
or specialized design” (British Standards Institution,
2005). While this concept displays similarities with
2. Explore: Determine “What are the needs?”
3. Create: Generate ideas to address “How can the
needs be met?”
4. Evaluate: Judge and test the design concepts
to determine “How well are the needs met?”
(University of Cambridge, 2017b)
Further details about these phases can be
found in the Inclusive Design Toolkit (University
of Cambridge, 2017b). Approaches to design and
building practice have evolved over many years in
response to society’s growing awareness of population diversity and the rights of people to be
included in all aspects of society regardless of age
244
Chapter 10
or disability. This has influenced the modifications,
products, and services that have been available and
offered to people as the perspectives have moved
from seeing people as “different” and requiring
specialized features to recognizing that all design
should be able to accommodate all people regardless
of their abilities. While this evolution has occurred
in a positive trajectory overall, there is still room for
further improvement and standardization of current
approaches to design, particularly at the international level.
CONCLUSION
There is a range of resources available to assist
therapists in locating and sourcing products and
designs. Each of these contributes different information and allows therapists to develop a portfolio
of products and designs suited to the needs of an
individual in a range of situations. Initially, therapists need to establish a broad understanding of the
diverse range of options available. They can then
build on this solid foundation to undertake a targeted search of resources to identify products and
designs suited to the specific needs of each client.
It is often difficult for therapists who are new to the
field or only undertake modifications as a small part
of their work to establish and maintain the expertise
required to do modifications well. In these situations, therapists need to consult with colleagues
with greater expertise to ensure the best outcomes
for their clients.
To determine the best solution in each case, therapists review and evaluate options by comparing the
features and specification of each, with due consideration to client priorities and preferences. Therapists
also draw on available evidence and use professional
reasoning to collect and interpret different types of
information to determine the best option for each
situation, assessing the quality and relevance of
information and applying it judiciously. Therapists
also need to be conscious of the standards when
selecting and evaluating products and designs while
remaining mindful of the specific needs of each client and his or her situation. Finally, therapists need
to ensure that products and designs incorporated
into modifications are aesthetic and recognize the
diverse and changing abilities of all residents of the
household while reflecting the expectations of society in terms of what a home should look and feel like.
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